Need better billing compliance tools? Here are some examples

CR site is small, but compliance is mighty

Cancer Care Northwest of Spokane, WI, is proof that a clinical research site doesn't need to be large to have a successful billing compliance program.

"We do some extra things that large academic centers don't do," says Rachel Garman, LPN, CCRC, a research manager in oncology.

There are systems to prevent billing mistakes, but all the billing reviews are done retrospectively, she says.

"Everything in our practice goes out in 24 to 48 hours after the patient was seen," she adds.

For instance, if a study requires an EKG that cannot be done in-house, then Garman will create a separate account that is research specific.

Those invoices first go to Garman so she can verify the amount before she sends them to accounts payable.

"If I don't get an invoice from the vendor, I'll call the vendor to make sure they didn't send it to the patient," Garman says.

It takes a little time to get everyone aware and actively implementing the correct billing process, she says.

"I noticed once we started providing our billing people with more education on billing compliance that things got a lot better," she adds.

Garman describes some of the compliance program's billing tools and how these assist with improving compliance:

• Research patient billing guide: For example, the research site has created a simple billing guide that details precisely what a clinical trial will pay for, what should be billed to the patient's insurance, and how these study procedures apply to ICD-9 and CPT codes.

"It's a guide that says, 'This is what the trial pays for, and when you get these items, they should not be billed to a third-party payer,'" Garman says.

The billing guide lists the patient's name, date consented, the doctor's name, the study number, an account number, and research start date, as well as a description of details.

It also includes a table that lists the CPT/J codes, procedure, DOS, and when it was performed. The main sections are for lab procedures, chemotherapy, radiology, office visits, markers, and anti-emetics.

At the bottom of the form it clearly states, "Any items marked on this sheet are not to be billed to patient insurance. Any questions, please call the study coordinator."

• Billing guide distribution list: The billing compliance program also has a billing guide distribution list that includes the people who need to be notified when a patient begins a clinical trial. These would include the research staff, billing staff, pharmacy staff, and financial counselors who do pre-authorization, etc., Garman says.

"We don't notify the clinical staff until the patient is on the trial, but then the clinical staff isn't involved in billing the patient on the clinical research trial," she adds.

• Reimbursement alert and log: Another tool is the site's reimbursement alert, which was created for each study patient.

"Before billing for a research patient's visit, the biller will look at that alert to see what should not be billed to a third-party payer," Garman says.

"Our internal billing person who is looking at all of those charges knows which charges to scrub on the back-end, which drug administration needs to be taken out and not billed to the patient," she says.

The reimbursement log is a Microsoft Excel spreadsheet that has 13 columns. The first column lists the patient's name. It also lists the patient's initials, identification number, cycle of data, data registered, dollar amount received, date received, J code/CPT/NSOC procedure, DOS, performed by date, money received by cancer center, contract dollar amount, and insurance audit verified.

"We keep track of all patients on the reimbursement log, so I know exactly what day the patient got treatment, what was billed to insurance, and what was scrubbed on the back end," Garman says. "I use that as a guide to meet with my billing contact, and we look at every one of those patients to see if it was billed correctly."

Compliance specialists can review this log more quickly after they have some experience with it, she notes.

"The first time we sat down with it, we spent a good eight hours reviewing it," Garman recalls. "Now it takes us one to two hours to look at all of the patients."

When they discover problems, they designate the person responsible for fixing it, and later record the date it was fixed, she adds.

"We have a list that determines any issues, and we send it to a billing person and the director of finance," Garman says. "We tell everyone what the issues are, and the form gets sent back to me once they've corrected it."

They also make a note to follow-up on the problem.

"If the issue is that someone was billed incorrectly, then we contact the person who does refund to make sure it's taken care of," Garman says.

• Track and trend: "It's all about tracking and trending," Garman says. "If we notice one trial or one person who has a chronic issue, then we'll dig deeper and analyze the root cause."

Garman will look at the whole process to find the cause.

For example, Garman once put incorrect information in the electronic medical record.

"It was a simple mistake where I said this is paid for by the study when it wasn't," she explains. "So the breakdown was on my part."

She went back to change the electronic medical record's alert and the communication in the billing guide.

"I sent a notice to the billing manager and manager of research to say the information was put into the electronic medical record incorrectly," Garman says.

Other times, mistakes can occur when there's a hand-off between billing specialists, such as when the main person is on vacation.

The CR site provides training to all involved staff, but it's also important to provide billing staff with contact information for the research manager. This way they can always call if a question arises when one biller is filling in for another one.

"When you take a good look at billing issues it becomes clear where you've had downfalls and where your risk categories are and how to fix them," Garman says.