Maximize Your Revenues with Mid-Level Practitioners
With expenses growing and collections shrinking, the utilization of mid-level practitioners has become very common in Emergency Departments across the United States. Mid-level practitioners are as common as template charting systems. Groups adding coverage these days often look to add hours with mid-levels rather than physicians due to the cost savings. Mid-level utilization has evolved such that they are operating in conjunction with Emergency Physicians in the main unit, work in triage, and work as stand alone coverage to patients triaged to the fast-track or urgent care areas of the Emergency Department. While you save money on the front-end due to lower cost of staffing, you could be losing money on the reimbursement end.
Mid-Level Practitioner Trends
A recent conversation with a company provided the topic for this article. After speaking with their directors, it was clear that they employed mid-level practitioners but did not understand how to credential and bill for them. Reimbursement for mid-level practitioner services is changing as rapidly as our industry. For years, only Medicare provided a reduction for mid-level services (15%). Now, many State Medicaid plans, BC/BS plans, and other private insurers have followed suit. If I had to guess, this is only the beginning and most if not all plans will credential and pay less in the future for mid-level services. Therefore, it is imperative that you understand how to credential and bill for mid-level practitioners such that you avoid risk of false claims while maximizing your collections.
Mid-Level Practitioner Reimbursement
Before you begin hiring and/or billing for mid-level practitioners, do your research so that you clearly understand the rules as they relate to Medicare, Medicaid, BC/BS, and all other large managed care plans in your area. With many of the aforementioned plans, you will need to credential and bill for mid-level services with their own provider number and most often you will receive 15-25% less reimbursement. Less reimbursement doesn't sound good; therefore, I will bill under the doctor who co-signs the chart. While many people still do this and some may even advise you that it is okay, billing claims for a mid-level when the physician only co-signs the chart is grounds for a false claim in many cases, especially Medicare. Make certain you understand the billing and documentation rules for your major payors and advise the physicians and mid-levels.
Maximize Reimbursement
How do I keep from losing the 15-25% on mid-level claims? To date, Medicare and the other carriers that recognize and credential mid-levels require that the physician have a face-to-face with the patient. While face-to-face is not clearly defined at this point, we recommend that the physician working with the mid-level document his or her involvement with the patient separately. Furthermore, I encourage physicians to make their face-to-face involve at least a brief physical exam and/or explaining the course of treatment. If this type of face-to-face is documented, the claim may then be billed under the physician and thus the 15-25% is not lost. While the utilization of mid-levels within certain emergency departments doesn't lend itself for the physician to have a face-to-face with every patient, you have the option to implement this type of flow to maximize revenues and reduce risk. With some groups, this decision will result in over $100,000 of annual collection; therefore, evaluate your mid-level utilization and documentation carefully prior to billing their claims.