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Tips to Calculate Payer and Gross Collection Ratio in Accordance with MIPS for Your Podiatry Facility

Tips to Calculate Payer and Gross Collection Ratio in Accordance with MIPS for Your Podiatry Facility

The net collection rate is an essential medical billing metric to measure the ability of your practice to collect the money it owes.

Podiatrists will not be able to succeed within the MIPS payment structure without a QCDR. While it is possible initially to continue to report PQRS via claims or using the method of “hand entering” data, submitting PQRS data via the USWR QCDR is what will allow podiatrists to use the Podiatry Specialty Quality Measure Group proposed by the APMA. The USWR also sponsored the APMA’s vascular screening quality measure and comprehensive diabetic foot exam quality measure, as well as 19 other wound care specific quality measures.

In addition for quality measure reporting, submitting data to the Podiatry Registry earns points for Advancing Care Information. The MIPS model is scheduled to begin in 2019, but 2016 is a crucial year. A provider’s performance in quality reporting programs in 2016 will affect the final MIPS score.

MIPS, the merit-based incentive payment system, use a score on a 100 point scale to grade your practice’s performance in four different categories. These performance categories include:

  • Meaningful use
  • The value-based modifier payment system quality as determined by the Physician Quality Reporting System standards
  • Use of vbm payment resources
  • Your clinical practice improvement

The points earned in each category will have a significant impact on the financial well-being of your practice.

The Centers for Medicare and Medicaid Services (CMS) has set a standard “performance threshold” of 50 points. You must satisfy at least 50 points to avoid paying a penalty. If your practice scores a 50, your payment adjustment will be 0 percent – generating neither penalty nor reward. However, if your practice scores 51 or above, you might receive additional financial compensation.

Payer Mix Ratio

It’s important to determine the value of an insurer to your practice. Calculate the ratio for each contract to determine how the individual plan or company contributes to your overall financial success.

If one or two companies dominate this statistic, make sure you develop the best possible working relationship with them. If you have a particularly hard-to-work-with plan which is responsible for a small percentage of your practice revenue, consider the possibility of terminating your participation with that plan.

Payer Mix Ratio = Individual Payer Receipts / Total Receipts

As an alternative to the Payer Mix Ratio, consider calculating the Payer Ratios. Replace receipts with adjusted charges. This ratio indicated what you should have received from various payers. When the actual collections differ significantly from what you should have collected, the problem often is the result of contractual write-offs.

Gross Collections Ratio

Gross Collections Ratio is a ratio that shows how much of what you bill is actually received. To make sense of this ratio you must compare it with the net collection ratio. This helps determine whether your fees are too high or low.

Gross Collections Ratio = Total Collections / Total Gross Charges

Net Collection Ratio takes into account your contractual adjustments with the insurance companies. The measure incorporates your contractual disallowances – how much of what you’ve agreed to be paid much how you’ve actually received. Be careful in calculating this. In posting disallowances (contractual write-downs) with each third-party payer’s reimbursement, don’t assume that whatever has not been paid is a contractual disallowance. MCOs and other payers (including Medicare and the Blues) often disallow more than what was contracted.

Net Collection Ratio = Total Collections / Total Gross Charges

Timely Filing of Insurance Claims

Podiatry Billing Services uses a clearinghouse to send claims to payers. Claims are processed electronically and are date and time stamped. The batch of claims is submitted to each insurance company for review and payment. If a claim is denied for timely filing and there is proof that the claim was timely filed, it should be appealed. The appeal should include the patient’s name, date of birth, date of service, policy number, ICD-10 Codes, charges, the date originally filed and accepted. Most payers take 30 to 90 days for review of appeals.

Deadlines for timely-filing can vary by state. Below are examples of timely-filing deadlines for some of the larger payers:

  • Medicare: 365 days from the date of service
  • Blue Cross/Blue Shield: 6 months from the date of service
  • Cigna: 90 days from the date of service
  • Medicaid: 95 days from the date of service
  • United Healthcare: 90 days from the date of service

For more information about timely-filing visit the payer’s website and look under the provider section for timely filing deadline. It’s very important to know the deadlines for carriers in your state. Holding claims can result in non-payment due to timely filing.

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