Money Matters: All of Your Billing Questions Answered

1

• Money Matters All of Your Billing Questions
  Answered
• Advocacy and Negotiation for Improved Health Plan
  Coverage and Reimbursement
• Steven C. White, PhD
• Director, Health Care Economics and Advocacy
• American Speech-Language-Hearing Association
• CSHA Spring Conference
• Aurora, CO
• May 2, 2009
• 830 345 PM

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Todays Agenda

• ASHA Strategic Pathway to Excellence and
  Reimbursement Initiative
• Key players
• Negotiation and persuasion your negotiation
  style
• Developing an action plan

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Agenda, contd

• Calculate costs fees for negotiating
  reimbursement rates
• Medicare speech-language pathology pathologist
  private practice enrollment
• Procedure codes and valuing procedures and
  service
• Medicaid

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Your Billing Questions Answered

• All of them?
• reimbursement_at_asha.org
• swhite_at_asha.org

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Resources

• Reference materials
• Some used during the seminar
• Include them during the presentation

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Pathway to Success

• Goal? Improve Private Plans Coverage
  Reimbursement for Speech-Language Pathology
  Audiology services
• How? Through Decision-makers
• Managed Care Company
• Employers that Self-Insure Employees-Benefits
  Managers, Human Resources Department
• Organizations
• Legislators
• Clients
• Pathway? Prepare, Strategize, Educate,
  Negotiate/Persuade

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2008 - 2009 Strategic Objectives

• Negotiating Private Health Plan Coverage
  -Advocacy Seminar presented at State
  Associations annual conventions
• Actuarial Data from Milliman -
• Available in Negotiating Health Care Contracts
  and Calculating Fees
• Purpose For use by State Speech-Language
  -Hearing Associations, especially STAR Network
  Members

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2008 - 2009 Strategic Objectives, contd

• State Advocates for Reimbursement (STARs)
• Educational programs for the STARs
• Collaborating with ASHA on Strategic Objectives
• Listserv and member community forum
• Monthly conference calls

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2008 Strategic Objectives-contd

• State Advocates for Reimbursement (STARs)
• CSHA STARs Ann Pendley (SLP)pendley_at_frii.com
• Beth B O'Brien (AUD)beth_at_chsl.org
• Grant program for STARs
• Calling on coalitions

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2008-2009Strategic ObjectiveforReimbursement

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2008-2009 Strategies

• State Assn. Workshops
• STAR Meetings
• State Grants
• RBRVS Work Resource-based relative value
  scale and professional work rather than technical
  practice expense

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Business/Health Coalitions

• Developing Relationships with National Business
  Coalition on Health and National Business
  Coalition on Health
• NBCH mailing and membership listcan be used by
  STARs to reach employers in their states

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Business/Health Coalitions

• National Business Group on Health
• Collaborate on revising Investing in Maternal and
  Child Health
• www.businessgrouphealth.org/healthtopics/maternalc
  hild/investing/docs/mch_toolkit.pdf -
• First must set precedent with FEHBP

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FEHBP

• Federal Employees Health Benefits Program
• Covers 8 million lives
• ASHA seeking to add more comprehensive
  speech-language and hearing services
• Contacts with Congress and Office of
  Personnel Management

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FEHBP

• Improvements in FEHBPs coverage for SLP and AUD
  services could lead to similar changes in health
  care plans sponsored by other public and private
  organizations.

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FEHBP

• Preparing language for pediatric SLP benefit
• Core versus supplemental service
• OPMs 2007 Instructions for HMOs contains
  favorable language
• Parallels in Ohio?

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Environmental Situation

• Can you tackle a myriad of problems in one year?
• Can you agree on what is a major health plan
  problem in Colorado?
• How do you want it changed?
• Who do you see?

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Whos Who-Know the Players

• State Legislators
• State Regulators (Department of Insurance)
• Benefits Managers
• Health Plan Medical Directors
• Union Representatives
• STAR Representative
• You

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Resource Review

• What resources do you have?
• One or more dedicated individuals who own the
  issue?
• Documented problems?
• Support from other organizations?

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Impact of Laws and Regulations

• Federal law - Employee Retirement Income Security
  Act (ERISA)
• Exempts self-insured employers from some state
  mandates
• Any Willing Provider (AWP) Laws
• Cannot discriminate against any provider willing
  to meet the health plans terms and conditions
  for network participation

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State Laws and Regulations

• Investigate health insurance statutes and
  regulations
• Determine if your state currently mandates
  benefits see www.cahi.org/cahi_contents/resources
  /pdf/HealthInsuranceMandates2008.pdf
• Locate relevant laws with the help of your state
  associations lobbyist and the Insurance
  Commissioners office

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Colorado Mandates

• Related health benefits autism
• Related providers psychologists, social workers

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Current Attitude in State Capital

• Determine the current climate for amending state
  law
• Discuss issues with colleagues in human resource
  departments
• Determine reactions with state legislators

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Insurance Commissioner

• Elected OR appointed
• Party affiliation AND bias
• Public statements regarding state law and health
  insurance
• Local Insurance Commissioners web page
• National Association of Insurance Commissioners
  (www.naic.org)

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Attitude of Insurance Companies

• Check BC/BS Assn. and other insurers websites
  for news and information (www.bcbs.com)
• Expect insurers to firmly oppose any mandates
• Success of recent legislation

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Trends in Employer Health Benefits

• Employers increasingly look for ways to cut
  health care insurance costs.
• Major Strategy Drop or reduce scope of benefits.

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Employer Strategies

• Employees share more cost of health plan
• Co-pay
• MSA, FSA, HRA
• Association plan or some form of joint
  coverage

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New Approaches

• Flexible Spending Accounts (FSAs)
• Health Reimbursement Arrangements (HRAs)
• Health Savings Accounts (HSAs)

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Trend to Watch

• Health Savings Accounts
• HSAs are savings accounts into which individuals
  deposit money and then withdraw it tax-free for
  eligible medical expenses.
• HSAs implemented in 2004 through a change in the
  Internal Revenue Code to allow an individual to
  deduct HSA contributions.
• HSAs require a high-deductible health plan
  (HDHP)a plan that features higher annual
  deductibles than other traditional health plans.
  Those who hold HSAs are responsible for
  researching health coverage options and keeping
  careful track of their financial and medical
  records.

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HSA

• Covered expenditures include medical costs that
  may not be included in some standard health
  insurance contracts but are considered tax
  deductible medical expenses by the Internal
  Revenue Service (IRS).

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HSA

• The IRS has specifically deemed the following
  expenses to be included in their definition
• Therapy received as a medical treatment
• Special education expenses paid on a doctors
  recommendation for a childs tutoring by a
  teacher who is specially trained and qualified to
  work with children who have learning disabilities
  caused by mental or physical impairments

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Health Savings Accounts

• ?Must be paired with high deductible health plan
  (HDHP)
• ? Maximum contributions are 2,600 annually for
  singles and 5,150 for families
• ? Contributions can be made by employer or the
  employees family members
• ? Employer contributions are voluntary
• ? Ownership may transfer to spouse upon death of
  employee
• ? Allow rollover of unused funds from year to
  year

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Employer Trends

• Providers need to continually justify the cost
  of their services by demonstrating a return on
  investment (RoI).
• ASHA had Milliman include new data in the most
  recent report as well as state information.

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Message

• Prevention and treatment of communication
  disorders are cost effective services that
  should be included in all private health plans
  because

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Message

• Nearly 50 million Americans have a speech,
  language or hearing disorder
• Approximately 30 million Americans have hearing
  loss
• One million Americans suffer brain damage each
  year from strokes, accidents, or brain tumors,
  resulting in speaking, hearing or swallowing
  disorders.

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Message

• If untreated
• Swallowing problems (dysphagia) can lead to
  respiratory complications such as aspiration
  pneumonia and/or malnutrition
• Hearing loss can lead to high blood pressure,
  coronary artery disease and elevated cholesterol
  and lipids

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Support

• There are articles in peer-reviewed journals
  showing the need for SLP coverage.
• Unmet need for therapy services, assistive
  devices, and related services data from the
  National Survey of Children with Special Health
  Care Needs, Stacey Dusing, et al., Ambulatory
  Pediatrics, Volume 4, Number 5, September-October
  2004, 448-454.

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Support

• Managed care utilization review in action at two
  capitated medical groups. Kanika Kapur, et. Al,
  Health Affairs, June 18, 2003.

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The Players Case Studies

• Where would you start?
• How do you think various players might react to
  or address the issue you present?
• (See scenarios)

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How to Bargain to Gain An Advantage

• excerpts from Bargaining for Advantage
  Negotiation Strategies for Reasonable People

by Professor G. Richard Shell Director, Wharton
Executive Negotiation Workshop Wharton School of
Business University of Pennsylvania
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Bargaining for Advantage

• Use to negotiate coverage and reimbursement in
  PHPs
• Apply to our meetings with payers
• Prepare by knowing who you are and what you can
  bring to the table
• Target the correct people?

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Negotiations 4 Steps
Closing Commitment
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Negotiation Skills Question , Listen
Negotiating Skilled Average Behavior
Negotiators Negotiators

• Questions, as Percentage of All
• Negotiating Behavior
• Active listening
• Testing for understanding
• Summarizing

21.3 9.6
9.7 4.1 7.5 4.2
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Four Steps

• Step 1 Preparing your strategy
• Step 2 Exchanging information
• Step 3 Opening and making concessions
• Step 4 Closing and gaining commitment

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Six Elements of Effective Negotiation
III Authoritative Standards
IV Relationships
V Their Interests
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Psychological Foundations of Negotiations
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Preparation Step 1

• Assess the situation construct a specific plan
  of action
• Use the Information-Based Bargaining Form
  approach found at the end of Tab 2

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Persuade Make a Good Case

• Credibility Increases Influence ?
• Influence Increases Your Power to Persuade
• Knowledge is Power!
• Prepare Arguments Persuasion Points in Advance
• Demeanor Sets the Tone Relax, be pleasant,
  cooperate Enjoy the Experience!
• Build Rapport, Empathize Recognize, echo other
  persons viewpoints constraints
• Draw out Hidden Information Find Leverage
  Points
• Ask Questions Listen! Listen more than Talk!
• Set up Chain of Agreement Steps Lead to
  Ultimate Persuasion Points

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Situational Matrix
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A Strategy Guide
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Negotiating The Pacer Case

• Do Your Best - Be Creative!
• Make it Real - Pretend info sheet is not there
• Accelerate Time - if you must, to reach a deal
  (or impasse)
• Dont discuss the case with anyone
• we will all discuss it together

Rules
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The Pacer Case Results

• No Deal
• 0 -- 500
• 501-- 1000
• 1001 1,500
• 1501 2,000
• Over 2,000
• Any other aspects to an agreement???

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Step 2 Exchanging Information

• Purpose 1. Establishing rapport
• Purpose 2. Obtaining information on interests,
  issues, and perceptions Dont be a
  blabbermouth negotiator ask questions.
• Purpose 3. Signaling expectations and leverage

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Step 3 Opening Making Concessions

• Question 1 should I be the first to open?
• Question 2 should I open optimistically or
  reasonably? (model benefit or shape to situation)
• Question 3 What sort of concession strategy
  works best? (leave yourself bargaining room)

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Negotiate Execute a Good Strategy

• Opening Where and Why
• Concessions When to concede, How much, and Why
• Closing When to close, When to walk away, and
  Why

You got to know when to hold em, know
when to fold em, know when to walk away, and
know when to run The Gambler by Kenny
Rogers http//www.youtube.com/watch?vkn481KcjvMo

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Negotiation Stage 3 Opening Concession
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Negotiation Art

• Win-Win Attitude Sets the Tone
• Listen - Solicit Information to Find Leverage
• Set up a Chain of Agreement so steps lead
  other to concede your ultimate points
• Compromise
• Meet between Positions
• Give to Get (Reciprocity is the Norm)
• The Lagniappe - Add the Unexpected
• Know when to STOP! Dont Oversell!

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Good Guy/Bad Guy

• Good guy opens the negotiation with friendly
  rapport-building chatter
• Bad guy opens with an outrageous level or attacks
  our proposal
• Good guy steps in a insists that bad guy make a
  concession
• You should find out who has authority to agree
  with what.

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Negotiation Games

• PRE-EMPTIVE GAMES - Purpose Makes you think you
  already won points, softens your motivation to
  bargain big items
• GOOD GUY/BAD GUY RUSE
• Good Guy opens- Friendly, rapport-building
  chatter
• Bad Guy opens- Attacks you, your Proposal or
  Position
• Good guy insists his colleague make a
  concession (uses give-away chip meaningless to
  them)
• . . . .You think you already scored Dont Buy
  It!

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Step 4 Closing Gaining Commitment

• Closing factor 1 The scarcity effect what you
  have is in great demand
• Closing factor 2 Overcommitment to the
  bargaining process like standing in line and
  learning that there is a long wait stringing
  you along and then springing a last-minute demand

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Closing

• What do you Want? Be Clear!
• I want higher fees for work performed.
• Value Pay should be based on actual hours and
  expense
• Insurers should cover Speech-Language services
  based on medical necessity, not exclude them
  based on etiology.
• Value Patients medical needs should be
  paramount and treated equally
• I want a legislative mandate for hearing aids.
• Value Society should ensure that people can
  hear.

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Information-Based Bargaining

• Solid planning preparation
• Careful listening
• Attend to the signals

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Six Factors/Foundations

• Personal bargaining style
• Your goals expectations
• Authoritative standards norms
• Relationships
• Other partys interests
• Leverage (composed of diverse ingredients of
  bargaining assets)

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Your Bargaining Style

• Path of negotiation gifts are universal
  language
• Four step path preparation, information
  exchange, explicit bargaining, commitment
• A negotiation is an interactive communication
  process that may take place whenever we want
  something from someone else or another person
  wants something from us.

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I. Bargaining StylesValuable Personal Traits

• Willingness to thoroughly prepare
• High expectations self others
• Patience to listen
• Commitment to personal integrity
• Optimism

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I. Bargaining Styles Exercise 1 Your
Bargaining Style Quiz

• Bargaining Styles Assessment Tool (Quiz Handout)
• Courtesy of G. Richard Shell, Wharton School of
  Business
• Please select ONE STATEMENT in each pair of
  statements you think is more accurate for you
  when you face a disagreement - even if you think
  neither statement is very accurate or both are
  very accurate. Do not revise your answers.
• Pick the one your gut tells you is more accurate
  most of the time for such situations in general
  not only at work or home. Do not pick the
  statement you ought to agree with
• Record A, B, C, D, or E for each answer. Some
  statements repeat - do not worry about answering
  consistently. Just keep going. All answers are
  equally correct in some circumstances.

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I. Bargaining Styles Exercise 1 Your
Bargaining Style Quiz Results

• ADD YOUR A, B, C, D, AND E QUIZ ANSWERS
• ENTER THOSE TOTALS
• As _______ (Competing)
• Bs _______ (Collaborating)
• Cs _______ (Compromising)
• Ds _______ (Avoiding)
• Es _______ (Accommodating)
• _______ TOTAL (equals 30)
• How do your results compare with U.S. Executives?
• (See Graph attached to Quiz)

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I. Bargaining Styles Comparative Bargaining
Styles
Concern for Own Outcome
HIGH
LOW
HIGH
Collaborator/ Problem-solver
Accommodator
Concern for Others Outcome
COMPROMISER
Competitor
Conflict Avoider
LOW
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BEYOND STYLE - Effective Persuasion
Negotiation Abilities

• Key Abilities You Can Develop
• Strategic Thinking
• Good Memory or External System - quick info
  retrieval
• Reading Body Language
• Asking Questions Listening Well
• Being Verbally Quick
• Handling Stress Well
• Positive Attitude just as important as
  ability!

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Your Bargaining Style -2

• If you are basically an accommodating, nice
  person, dont try to be a hard-nosed negotiator
  or try to be a super-competitive
• What is your style?
• 10 people at a table an offer is made to give
  1,000 to each of the first 2 people who can
  persuade the person sitting opposite to get up,
  come around the table, stand behind his or her
  chair.

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Your Bargaining Style - 3

• Five types
• Competitors
• Problem solvers
• Compromisers
• Accommodators
• Conflict avoiders

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Your Bargaining Style - 3

• Cooperative v. competitive
• Studies show cooperative style is more common
• Take people as you find them
• Prudent to take a minute to see just whom you are
  really up against.

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Beyond Style To Effectiveness

• Attributes to a skillful negotiator good
  memory
• Being quick verbally
• Handling stress well
• As much a matter of attitude as ability

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Key Habits/Bargaining Style

• Willingness to prepare
• High expectations
• Patience to listen
• Commitment to personal integrity

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Second Foundation

• Goals and Expectations
• I believe in always having goals and always
  setting them high. Sam Walton

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II. GOALS

• Effective Negotiation Goal
• Well-Prepared Target
• Belief in Fairness, Legitimacy, Feasibility
  Persistence

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Goals Expectations - 2

• Goals Youll never hit the target if you dont
  aim
• What you aim for determines what you get
• Goals set the upper limit of what you will ask
  for
• Setting specific goals motivates people
• We are more persuasive when committed to
  achieving some specific purpose

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Goals Expectations - 3

• Setting goals
• Think carefully what you really want money is
  often a means not an end.
• Set an optimistic but justifiable goal.
• Be specific
• Get committed write down your goal discuss
  with someone else
• Carry your goal with you to negotiations

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Third Foundation

• Authoritative Standards Norms
• Human natures most basic psychological drives
  our need to maintain (at least in our own eyes)
  an appearance of consistency and fairness in our
  words and deeds.
• Maintain consistency

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Authoritative Standards - 2

• We all want to appear reasonable
• We feel uncomfortable when the other side
  correctly points out that we have been
  inconsistent
• Consistency principle can give normative
  leverage in negotiations
• Anticipate the other sides preferred standards
  and frame your proposal with them.
• Beware of consistency traps.

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Authoritative Standards - 3

• Positioning themes
• A crisp, memorable phrase or framework that
  defines the problem you are trying solve in the
  negotiation.
• Shows the other party why you are there and helps
  you keep your eye on your own goals.

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Authoritative Standards - 4

• The power of authority
• Human tendency to defer to authority
• Authority can become a problem in negotiations
• Others may seek to exploit our tendency to defer
  to authority
• Our deference to authority sometimes
  inappropriately interferes with our ability to
  assert our own legitimate interests

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Fourth Foundation

• Relationships
• Leave a good name in case you return. Kenyan
  Folk Saying
• Personal relationships create a level of trust
  and confidence.

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Relationships - 2

• Norm of reciprocity
• Always be trustworthy and reliable yourself.
• Get into the habit of reviewing the relationship
  factor as a routine part of effective negotiation
  planning.
• Relationship factor makes a big difference
• A working relationship is more formal than
  friendship.

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Relationships 3

• Strategies for building working relationships
• Similarity Principle
• Role of gifts and favors
• Trust and relationship networks (e.g., alumni
  networks, community activities)

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Relationships 4

• Traps for the unwary
• Trusting too quickly
• Negotiating with friends when the stakes are too
  high

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Fifth Foundation

• The OtherPartys Interests
• See the world from the other partys point
  of view

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Other Partys Interest 2

• Discover the other partys goals
• Why is it so hard?
• We see the world through our own self-interest
• We are all somewhat competitive
• The dynamics of the negotiation process work
  against us
• So, take the effort to find the common ground

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Other Partys Interest - 3

• Planning behavior1. Identify decision
  maker2. Look for common ground3. Identify
  interests that might interfere with agreement4.
  Search for low-cost options that solve the other
  partys problems while advancing your goals.

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The Sixth Foundation

• Leverage
• The balance of needs and fears
• Work your way through a high-stakes bargaining
  situation and ask yourself who has the leverage
  at each step of the way.
• Who controls the status quo?

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What is Leverage?

• Leverage is situational advantage--the ability to
  HELP or HARM the other party. No matter how
  hopeless it seems, every party has SOME leverage.
  (If not, there's no negotiation, simply demand
  and obedience.) Unlike formal authority and
  power, leverage can change often during a
  negotiation.

92
Leverage

• Positive leverage the carrot-- "Here's what I
  can give you."
• Negative leverage the stick--"Here's the trouble
  I can cause you."
• Consistency leverage "Here's the principle you
  stand for--now live up to it."

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Leverage - 2

• For whom is time a factor?
• Create momentum give them little things
• Create a vision that the other side has
  something to lose from no deal.

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Leverage 3

• Three types of leverage
• Positive
• Negative
• Normative
• Best alternative to a negotiated agreement (BATNA)

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Leverage 4

• Positive leverage uncover everything the other
  side wants
• Negative leverage threat leverage like dealing
  with explosives
• Normative leverage both parties stand to lose
  equivalent amounts should the deal fall through.

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Leverage 5

• The power of coalitions
• Can you create an effective coalition?
• Professionals and consumers
• Other professionals
• Will they interfere with your position?

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Leverage - 6

• Common Misconceptions about Leverage and Power
• Leverage power are the same(?) things
• Leverage is a constant that doesnt change,
  depends on facts
• Power is?

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The Negotiation Process

• Step 1 -- Preparing your strategy
• Step 2 -- Exchanging information
• Step 3 -- Opening and making concessions
• Step 4 -- Closing and gaining commitment

99
Initiating Contact

• IDENTIFY a health plan, employer, or other entity
• REVIEW the current health plan or employer
• What is covered?
• What are the limits?
• TARGET the decision maker
• Human Resources Director
• Benefits specialist
• Union representative

100
Initiating Contact

• ARRANGE a meeting to discuss
• Incidence and prevalence
• Services provided by audiologists and
• speech-language pathologists
• Coverage issues
• Costs to add services
• Consumer satisfaction surveys

101
Initiating Contact

• At your meeting, discuss
• Credentials held by audiologists and
  speech-language pathologists
• Medical necessity of your services
• Treatment effectiveness ASHAs National Center
  for Treatment Effectiveness in Communication
  Disorders
• (For information, call 301-897-0101)

102
Initiating Contact

• PREPARE for the meeting
• Benefits administrators and medical directors
  pose very direct questions
• Preparation is the only aspect of negotiation
  over which you have complete control
• FOLLOW UP IS ESSENTIAL!

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PERSUASION NEGOTIATION

• MOST ESSENTIAL COMMON ELEMENTS
• Define The Problem
• Define The Solution
• Know Yourself
• Know Your Audience
• Prepare

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PERSUASION

• Develop Polish Your Idea
• Map the Formal Social Networks of Influence
  They are often not the same! Who knows whom?
• Who are the main decision makers? Who influences
  whom?
• Map a Stepping-Stone Influence Process
• Choose Your Persuasion Goals for Each
  Decision-Maker
• Tailor the Approach for Each Decision-Maker

105
Exercise Persuade a Legislator

• What style will work best?
• Does the legislator have any common ground with
  your idea? Past votes on similar issues, similar
  values?
• What will motivate acceptance for your idea?
• What are potential gains losses for the
  legislator? For you?
• What can you do for the legislator?

106
III. Standards

• Benchmarks suggesting a fair outcome
• Characteristics of a useful standard
• Independent Comes from outside the party
  advocating it
• Legitimate The other party recognizes or
  believes the standard to be fair
• Practical Easy to describe
• Constraining Narrows range of outcomes

107
IV. Working Relationships The Rule of
Reciprocity

• The practice of give and take
• We give information and receive it
• We make a concession and receive one
• We do a favor we are owed a favor

108
V. Interests

• IDENTIFY
• Shared Interests
• Patient Satisfaction, Good Patient Outcomes,
  Cost-Effectiveness
• Conflicting/Opposing Interests
• Higher Fees vs. Lower Fees
• Ancillary, Compatible Interests
• Reputations, Timing of Payment, etc.

109
VI. Leverage Perception

• PERCEPTION REALITY
• Who has the most leverage?
• Party who thinks they have the least to lose
  from No Deal
• Who has the least leverage?
• Party who thinks they have the most to lose from
  No Deal
• Compare Leverage Across the Table
• Not with ideal or worst-case scenarios. Compare
  your state with theirs
• Dynamic - Changes in a New York Minute as
  perceptions, conditions, players change

110
VI. Leverage Analysis

• Leverage In the Eye of the Beholder
• What do I lose if there is No Deal?
• What steps or alternatives will reduce my losses?
• If No Deal, what will other party lose?
• Can I influence their alternatives or make their
  status quo worse?
• Leverage Factors Me? Other Party? About
  Even?
• Who has the most to lose from No Deal overall?
• Source Shell, G. Richard, Bargaining for
  Advantage (New York Penguin Books, 2006)

111
Problems Projects

• PROBLEM SOLVING A Prelude to Success
• Define the Problem Your Target
• Policy? Error? Insufficiency? Ignorance?
• Problem Elements- Break it Down!
• System Flaws that Create Problems - What? Where?
• Describe Diagram the System
• Identify System Flaws - Which Need Change?
• Power Agents - Who can Correct System Flaws?
• Power Agents - Motivations Barriers
• Context? Economic, Political, Practical
• To Act or Not to Act? That is the Question!
• (Paraphrase d, Courtesy of William Shakespeare)

112
Exercise Mock Project Proposal

• Project A temporary activity with start date,
  goals, conditions, defined responsibilities.
• Define Problem
• Investigate Verify Problem Perception vs.
  Reality
• Identify Stakeholders Whom Does Problem Affect?
• Conceive Potential Solutions - Pros, Cons,
  Success Barriers?
• Use Priority Needs Values to Judge Solutions
• Choose Solution to Best Meet Priority Needs

113
Project Management

• Assemble Project Team Assign Roles
• Agree on Project Team Rules of Engagement
• Define Project Risks, Barriers, Goals, Action
  items
• Identify Project Customers
• Target of Projects impact who must pleased?
• Choose Deliverables Tangible work products,
  letters, flyers, educational tools
• Make Timeline Work backwards from target date
  to enter dates for Project Milestones (goals for
  Project stages, actions, meetings, completion of
  deliverables, Project completion. . .)

114
\Project FacilitationSocial Networks, Goals
Media

• From The Woo Worksheet
• Courtesy of G. Richard Shell and Mario Moussa,
  authors of the art of woo,
• (ISBN-13 978-1-59184-176-0 Portfolio of Penguin
  Group (USA), Inc., 2007)
• Social Network Analysis Whom should I speak with
  and in what order to reach the ultimate decision
  maker(s)?
• Goals What are my specific goals for my next
  encounter (gain input, access, favorable
  attitude, authorization, endorsement, decision,
  resources, implementation)?

115
Project Facilitation

• The medium is the message.
• Marshall McLuhan
• Communication Medium What characteristics of
  available media facilitate my message best? What
  are their pitfalls? What medium (face-to-face,
  phone, email) should I use for which situations?

116
POWER OF COALITIONS

• Will your Project Benefit from a Coalition?
• Pros Cons?
• Do you have/Can you create an effective
  coalition?
• Short-term or long-term coalition?
• Choose people/orgs with common interests
• Invite motivated SLPs Audiologists
• Should you invite other professions into your
  coalition? How, when?

117
POWER IN CHANGE

• YOU ARE THE AGENT OF YOUR OWN SUCCESS -- ITS UP
  TO YOU!
• POSITIVE THINKING LEADS TO POSITIVE ACTION
• STUDY ROLE MODELS FOR SUCCESS IDEAS
• BE A WINNER EVERY TIME GIVE YOURSELF DUE CREDIT
  FOR TRYING
• As Dr. Phil says,

Doing what youve always done gets you what you
always got. Hows that workin for ya?
118
DEVELOPING AN EFFECTIVE ADVOCACY PLAN

• What is Advocacy ?
• Advocate (n)
• 1 one that pleads the cause of another, one who
  pleads the cause of another before a tribunal or
  judicial court
• 2 one who defends or maintains a cause or
  proposal
• Advocate (v) to plead in favor of
• Synonyms support promote uphold defend argue
  for

119
Our Advocacy

• Convince third parties that comprehensive
  coverage of SLP and audiology services should be
  part of health plans
• AND/OR that our services should have appropriate
  payment levels

120
MEDICARE OVERVIEW

• Age 65 (inpatient coverage Part A)
• All ages, if with severe disabilities
• Almost all patients pay approx 100/month for
  Part B (covers individual practitioners)
• The co-pay is 20 of the published Medicare fee
  and you must collect the co-pay

121
Overview, contd.

• Private practitioners can see patients in
• one's office (conditions are subject to State
  regulations)
• in patient's home
• Assisted living facility qualifies as home
• Skilled nursing facility does not qualify

122
The Annual Therapy Cap

• 1840, combined with physical therapy services
• The Exceptions Process has, for the most part,
  eliminated the cap because
• When you add the "KX" modifier to the
  CPTprocedure code, it is certification that your
  documentation shows medically necessity
• The exceptions process has been re-authorized by
  Congress annually while an alternative to the cap
  is being developed

123
Enrolling in Medicare

• Regional carriers are contracted by the
• Centers for Medicare Medicaid Services (CMS)

124
An NPI Number is a Prerequisite to Medicare
Enrollment

• A National Provider Identifier (NPI) is required
  for all direct-bill practitioners under Medicare
• (Private health plans may require the NPI only
  for practitioners who bill electronically.)
• Apply online or by mail
• http//www.cms.hhs.gov/nationalprovidentstand/03_a
  pply.asp

125
NPI Application Tips

• Taxonomy code for SLPs (Level II classification)
  235Z00000X
• Provider Type 23
• _______________________
• Additional NPI for group
• practices ("Type II" NPI)
  

126
YOUR DIRECT LINK TO MEDICARE

• Medicare Carriers or Medicare Administrative
  Contractors (MACs)
• They process your enrollment application
• They process and pay your claims
• All carriers will transition to MACs by 2010
• Find carrier for your state (address, phone, web
  site)
• in "Medicare Fee-For-Service Contact Information"
• in the Provider-Supplier Enrollment page (next
  slide)

127
CMS PROVIDER-SUPPLIER ENROLLMENT SYSTEM

• http//www.cms.hhs.gov/medicareprovidersupenroll
• Click left side of page Internet-Based PECOS"
• PECOS Provider Enrollment, Chain and
  Ownership System
• PECOS is the preferred method for completing the
  enrollment application for individuals
• - - online interactive - -
  

128
Online PECOS Facilitates Completion of Form
CMS-855i

• Form 855i Application for Individual Health
  Care Practitioners
• PECOS detects information entered incorrectly or
  incompletely before submission
• You mail 2-page signed certification statement
  within 7 days of electronic submission
• Do not mail the statement until June 1, 2009!

129
Form 855i Individual Practitioners

• As an employee or contractor in a group practice
  
• If the practice is under your name or Doing
  business as or
• You are the sole owner of a professional
  corporation, professional association, or limited
  liability company
• If other SLPs work for you, also complete Form
  855B

130
If You Do Not Complete Form CMS-855i O N L I N E

• On your carrier or MACs Web site, enter in
  Search Box CMS-855i, for
• FAQs
• Contact information
• Mailing address
• Applications accepted as of June 2, 2009

131
Colorados MACs

• Noridian Carrier Part B
• TrailBlazer FI/Carrier Part A and B
• Local Coverage Determinations (LCDs)
• Detailed scope of coverage (1) Speech-language
  and (2) Dysphagia services

132
Related CMS Forms

• Can be submitted with the 855i or 855B
• CMS-460 Participating Physician or Supplier
  Agreement (optional)
• You agree to accept payment directly from
  Medicare instead of the patient (except for the
  patients 20 copayment)
• CMS-588 Authorization Agreement for Electronic
  Funds Transfers
• Allows payment directly to your bank account

133
Non-participating Status

• Send letter, requesting non-participating status
• Patient pays you Medicare pays patient directly
• As always, you must collect the 20 copayment
• You may collect a 15 limiting charge above 95
  of the fee schedule amount.
• (100 fee x 95) x 115 109.25)

134
To Enroll as a Group/OrganizationForm CMS-855B

• You complete the 855B
• Each employee/contractor
• completes the 855i if not already active in
  Medicare Part B
• Completes the 855R Reassignment of Medicare
  Benefits
• names the practice owner or corporation as the
  recipient of Medicare payments

135
You cannot treat Medicare patients if you have
not enrolled

• Informing the patient that you are not enrolled
  in Medicare and having the patients consent to
  be seen outside of the Medicare program is not
  allowed.

136
The CMS-1500 Claim Form

• Electronic billing is not required unless your
  practice has more than 10 FTE employees
• The CMS-1500 is also used by most practitioners
  for private health plans
• Medicare supplies free billing software
• You may want to investigate commercial billing
  software to enhance data collection and assist in
  clinical documentation

137
CMS-1500 Online Help Tools

• Form CMS-1500 at a Glance
• http//www.cms.hhs.gov/MLNProducts/downloads/form_
  cms-1500_fact_sheet.pdf
• Sources for purchase of the forms
• Source of CMS step-by-step instructions for
  completion
• Site for printing the form (not for submission)
• Instructions for completion are in Chapter 26 of
  the Medicare Claims Processing Manual
• www.cms.hhs.gov/manuals/downloads/clm104c26.pdf

138
1500 Top Portion
139
Medicare As Secondary Payer

• Medicare will pay after other insurance has been
  exhausted. Does not apply to supplementary
  insurance that covers what Medicare does not
  cover.
• Section 9 a-e
• Record spouse/partners insurance that covers the
  patient
• Section 11 a-d
• Record patient's other insurance

140
1500 Lower Portion
141
Recording Diagnosis Codes

• Section 21
• In spaces 14 insert ICD-9 codes
• Primary diagnoses (disorder being treated) are
  listed before secondary diagnoses (causes of the
  disorder you are treating)
• Section 24.E
• Insert 1, 2, 3, or 4 (links to the codes
  identified in Section 21) that describes the
  disorder you treated or evaluated

142
CPT Codes and Modifiers

• Section 24.D
• First block is for 5-digit CPT code
• Remaining blocks are for 2-digit modifiers
• Modifiers
• GN speech-language pathology service
• 59 distinct service (for CCI edits)
• 22 unusually long procedure (some MACs do not
  pay additional)
• 52 unusually short procedure

143
Place of Service Codes

• Section 24.B
• 03 School
• 09 Prison/Correctional Facility
• 11 Office
• 12 Home (where patient receives care in a
  private residence, not a facility)
• 15 Mobile Unit

144
PHYSICIAN CERTIFICATION

• A physician, physician assistant, or nurse
  practitioner must approve your plan of care (POC)
  during the first 30 days
• The approval can be effective for up to 90 days
  if the POC goals extend for at least 90 days
• Because of the certification requirement a
  physician referral or order is not required

145
NO SHOWS

• You may charge a fee for no-shows as long as the
  no show penalty is clearly explained in writing
  in advance ( days notice, penalty amount, etc)
• The no show policy is not otherwise regulated by
  Medicare. It is a policy that is between you and
  your patients.

146
CPT Coding and the Medicare Physician Fee Schedule
147
Special Otolaryngological Services

• Examples
• 92506 Evaluation of speech, language, voice,
  communication, and/or auditory processing
• 92507 Treatment of speech, language, voice,
  communication, and/or auditory processing
  individual
• 92508 Treatment group

148
Special Otolaryngological Services

• 92607 Evaluation for prescription for
  speech-generating device, face-to-face with
  patient, first hour
• 92610 Evaluation of oral and pharyngeal
  swallowing function
• 92526 Treatment of swallowing dysfunction and/or
  oral function for feeding

149
Central Nervous System Assessments/Tests

• 96105 Assessment of aphasia (includes assessment
  of expressive and receptive speech and language
  function, language comprehension, speech
  production ability, reading, spelling, writing,
  eg, by Boston Diagnostic Aphasia Examination)
  with interpretation and report, per hour
• 96125 Standardized cognitive performance testing
  (eg, Ross Information Processing Assessment) per
  hour of a qualified health care professionals
  time, both face-to-face time administering tests
  to the patient and time interpreting these test
  results and preparing the report

150
Physical Medicine and Rehabilitation

• 97532 Development of cognitive skills to improve
  attention, memory, problem solving (includes
  compensatory training), direct (one-to-one)
  patient contact by the provider, each 15 minutes

151

• ASHA WEB SITE - -
• MEDICARE CPT CODING RULES
• www. asha.org/members/issues/reimbursement
• /medicare/SLP_coding_rules.htm
• ICD-9 CODES Speech Hearing Related
• http//www.asha.org/members/issues/reimbursement/c
  oding/icd9.htm

152
Medicare Physician Fee Schedule

• Private practitioners, like all Medicare
  speech-language pathology providers, are paid
  established fees according to the
  procedures/sessions performed
• Medicare bases the payment on a resource-based
  relative value scale (RBRVS) of medical
  procedures
• The fees are established for all Medicare-covered
  Current Procedural Terminology (CPT) codes

153
2009 Medicare Fee ScheduleSpeech-Language
Pathology

• How some SLP codes are affected by the conversion
  factor (36.0666)

154

• ASHA WEB SITE - -
• MEDICARE FEE SCHEDULE
• http//www.asha.org/members/issues/
• reimbursement/medicare/feeschedule.htm

155
Clinical Documentation
156
Types of Documentation

• Evaluation
• Diagnosis, results of objective
• functional measures
• Plan of Care (POC)
• May be part of evaluation report
• Must be signed by physician
• Must be recertified by physician every 90 days
• Includes diagnosis, long term goals
• Type, frequency, duration of treatment

157
Types of Documentation, contd.

• Visit note Encounter note
• Date and duration of session, CPT codes billed,
  goals addressed signed by clinician
• Progress Report
• Every 10 sessions or once per 30 days, whichever
  comes first
• Progress toward goals modification of goals as
  needed prognosis
• Discharge Summary
• Reflects progress since last report

158
Documenting for Reimbursement Basic Medicare
Concepts

• Medical necessity
• Medical dx, treatment dx, functional impact,
  rehab potential/prognosis
• Skilled vs. unskilled service
• Analysis, treatment techniques, adjustment of
  plan
• Maintenance programs
• Outcome Measures (e.g., NOMS)

159
Writing Goals and Progress Notes

• Set specific, measurable, functional goals
• Address underlying impairments in reference to
  functional goal
• Document prior level of function
• Compare progress to baseline evaluation results
• Include amount of cueing, or communication
  context (complexity, environment) to add
  specificity to goals

160
Re-Evaluations

• There is no re-eval CPT code for SLPs so you may
  use 92506
• (Benefit Policy Manual, sec. 15/220.3.C)
• Re-evals are billable if overall change in
  condi-tion new clinical findings pre-discharge
  confirmation of goals met, etc (BPM, sec.
  15/220.3.C)

161
Where Do I Go From Here?

• ASHA Web site
• Professional Development
• Purchase tools and resources
• Networking, professional consultation

162
www.asha.org/members/issues/reimbursement/medicare
/SLPprivatepractice.htm
163
Resources on ASHA CMS Web Sites

• Medicare
• http//www.asha.org/members/issues/reimbursement/m
  edicare
• Coding for Reimbursement
• http//www.asha.org/members/issues/reimbursement/c
  oding/code_intro.htm
• http//www.asha.org/members/issues/reimbursement/c
  oding/
• Medicare CPT Coding Rules
• http//www.asha.org/members/issues/reimbursement/m
  edicare/SLP_coding_rules.htm
• Medicare Benefit Policy Manual
• http//www.cms.hhs.gov/manuals/downloads/bp102c15.
  pdf (scroll to sections 220.1, 220.2, 220.3,
  230.3)

164
Resources on ASHAs Web Site, contd.

• Medicare and SLP Private Practice
• http//www.asha.org/members/issues/reimbursement/m
  edicare/SLPprivatepractice.htm
• SLP Medicare Fee Schedule
• http//www.asha.org/members/issues/reimbursement/m
  edicare/feeschedule.htm
• Documentation Issues
• http//www.asha.org/members/slp/healthcare/documen
  tation.htm
• NOMS
• http//www.asha.org/members/research/NOMS

165
Professional Development

• Telephone Seminar Documentation for SLPs in
  Medical Settings
• Replay available until Dec 4, 2009
• www.asha.org/shop

166
Other ASHA Resources

• www.asha.org/shop
• Business Matters A Guide for Speech-Language
  Pathologists
• Guide to Successful Private Practice in
  Speech-Language Pathology
• Health Plan Coding and Claims Guide

167
Other ASHA Resources, contd.

• Medicare Handbook for Speech-Language
  Pathologists (available mid-2009)
• Negotiating Health Care Contracts and Calculating
  Fees A Guide for SLPs and Audiologists

168
Developing Reimbursement Codes and Valuing
Procedures

• Describe Your Services
• Current Procedural Terminology (CPT) helps
  describe what we do
• Employers and payers better understand knowing
  that the CPT lists our services
• The ICD-9-CM diagnoses can be helpful by
  describing the disorders for employers or health
  plan executives

169
Current Procedural Terminology - CPT

• 5-digit classification system
• Most widely accepted medical nomenclature
  recognized HIPAA code set
• Understood by professions, coders, payers,
  benefit managers

170
The CPT Process

• Developed and maintained by the American Medical
  Association (AMA)
• Multiple-step process (11-18 months)
• Codes and related values must be approved by two
  AMA panels

171
ASHAs Health Care Economics Committee

• Actively involved in third-party billing
• Sensitive to billing needs of colleagues and
  consumers
• Assist GRPP in determining current economic
  issues
• Develop goals for equitable reimbursement

172
Health Care Economics Committee

• Speech-Language Pathology Members
• Gretchen Bebb (TX)
• Becky Cornett (OH)
• Wayne Holland (CN)
• Bernard Henri (OH)
• Dee Adams Nikjeh, vice chair (FL)

173
Health Care Economics Committee

• Audiology Members
• Robert Fifer (FL)
• Richard Hogan (MO)
• Neil Shepard (MN)
• Stuart Trembath, Chair (IA)
• Robert Woods (NJ)
• Thomas Hallahan, VP GRPP
• Steven White, ex-officio

174
Benefits of CPT Codes

• Procedures uniform across practices
• Coders learn about our professions
• Payers learn about our professions
• We speak a common language

175
CPT Process (including valuation)
CPT Editorial Panel Defend Negotiate Rationalize
HCPAC CPT Board Members
ASHA Completes Request Form Collects Data Writes
Vignettes Collaborate w/ other organizations
RUC Relative Value Update Comm. (Relative value
assigned) Defend work skills RUC HCPAC Practice
Expense Professional Liability
CMS Value of Code Ranked Reimbursement Assigned
New CPT Book New Medicare Fee Schedule
Time Approximately 2 Years
176
CPT Development

• Codes are not discipline-specific
• Collaboration with related organizations
• Consensus building

177
CPT Development, contd.

• Codes are presented to the AMA CPT panel
• 17 members
• 11 physicians nominated by AMA
• 1 physician each nominated from
• Blue Cross Blue Shield Association
• CMS
• American Hospital Association
• Americas Health Insurance Plans
• 2 members of HCPAC

178
CPT Development, contd.

• CPT Health Care Professional Advisory Committee
  (HCPAC)
• Subcommittees of AMA CPT Panel and RUC
• The CPT HCPAC co-chair and one other HCPAC member
  represent all non-physician practitioners
• ASHA is represented on the CPT HCPAC

179
CPT Valuation

• Codes are then presented to the AMA Relative
  Value Update Committee (RUC)
• 28 members
• 23 appointed by national medical specialty
  societies
• 5 remaining seats one of each appointed by
• RUC chair
• HCPAC chair
• AMA
• American Osteopathic Association
• CPT Editorial Panel

180
CPT Valuation, contd.

• RUC Health Care Professional Advisory Committee
  (HCPAC)
• Subcommittee of the AMA RUC
• The RUC HCPAC chair represents all non-physician
  practitioners
• ASHA is represented on the RUC HCPAC

181
Physician Fee Schedule

• See Tab 9 Reimbursement Rates after the
  Milliman Report
• Medicare Physician Fee Schedules
• Note the tables in the Fee Schedule
• Will explain relative value units RVUs

182
97506

• Page 7
• Look at column heads
• CPT/HCPCS
• Mod
• Description
• Physician Work RVU
• Non-Facility Practice Expense
• Malpractice RVUs
• Non-Facility Total RVUs
• Fees (see geographic adjusters)
• We will use 92506

183
Relative Value Unit (RVU)

• Professional Component (Physician Work)
• -Added to procedures in which a physician (or
  other private practitioner recognized by
  Medicare) participates in the service
• 92506 0.86

184
Relative Value Unit (RVU)

• 2. Technical Component - TC
• (Practice Expense)
• Time spent to perform the procedure
• Time x salary per minute clinical staff cost
• The clinical staff cost and overhead costs
  (equipment supplies) are included in the
  practice expense
• 92506 3.04

185
Relative Value Unit (RVU)

• 3. Professional Liability
• Based on malpractice insurance premium data
• 92506 0.03

186
Total RVU

• Add the component RVUs
• 92506 3.93
• Conversion factor is 38.0870
• Fee is 145.77

187
RVUs Submitted to CMS

• CMS considers the values for each Procedure
• Resource-Based Relative Value Scale (RBRVS)
  procedures should be in a rank order
• Provision for budget neutrality

188
(No Transcript)
189
Calculating the Reimbursement Rate

• 2008 data
• CPT 92597 Voice prosthetic evaluation
• MD Work RVUs 0.86
• Practice Expense RVUs 1.84
• Malpractice RVUs 0.03
• TOTAL RVUs 2.73
• 2.73 x 38.087 100.07 (not 103.98)

190
Conversion Factor Impact

• Set by CMS to reflect sustainable growth rate
• Reflects Congressional mandates, e.g., 1999
  34.73152000 36.6137 2001 38.2581
  2002 36.1992
• 2003 36.7856
• 2004 37.3374 (1.5)
• 2005 37.8975 (1.5)
• 2006 37.8975
• 2007 37.8975 (initially -5.05)
• 2008 38.087 (initially -10.1)

191
Using Fee Data
192
Fee Data

• 2008 Medicare Fee Schedule
• 2008 National Fee Analyzer
• 2007 Milliman USA

193
Fee Data

• 50th percentile - 50 of charges are below this
  rate 50 of charges are at or above this rate.
• 75th percentile - 75 of charges are below this
  rate 25 are at or above this rate.

194
Price Setting

• Setting prices in collusion with colleagues is
  illegal! Violates federal Anti-trust (RICO)
  statute!