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COMPARATIVE BILLING REPORTS

THE BEGINNING OF THE END?

JOHN RUMPAKIS, O.D. M.B.A.

IN THE final week of October, fear was running high for many O.D.s — no it wasn’t Halloween that was scary, but a piece of mail from a company called eGlobalTech. Once again anxiety is running high because many of our peers are not keeping up with the declarative changes happening within the healthcare system in the U.S.

Comparative Billing Reports (CBRs) are one of four current initiatives being conducted by the Centers for Medicare & Medicaid Services (CMS) under the Division of Compliance, Projects and Demonstrations. All of these initiatives are detailed at http://go.cms.gov/1OzP0Us. More specifically, the CBR initiative can be found at CBRinfo.net.

What is a CBR and why are they being done? According to the CMS website, “A Comparative Billing Report (CBR) provides comparative billing data to an individual health care provider. CBR’s contain actual data-driven tables and graphs with an explanation of findings that compare provider’s billing and payment patterns to those of their peers on both a national and state level. Graphic presentations contained in these reports help to communicate a provider’s billing pattern more clearly. CBR study topic(s) are selected because they are prone to improper payments.”

Further, CMS indicates the reason for all of these initiatives is required by the Social Security Act to protect the Medicare Trust Funds against inappropriate payments that pose the greatest risk, and take the proper corrective actions.

AN AUDIT PRECURSOR?

No! Currently CBRs are educational tools disseminated to providers to provide insight into billing trends across regions and policy groups. Are CBRs new? No! CMS carriers have been producing and providing these reports to providers for years, but at a local level; now they have been formalized and expanded them to the national level. These are just one tool in addition to pre and post payment reviews (audits) to make practitioners aware of their individual billing patterns as compared to their state-based and nation-based peer groups. A sample CBR can be viewed at http://bit.ly/1QMri7P. The most recent CBR sample issued to O.D.s compared three billing patterns:

• Percentage of Comprehensive General Ophthalmological Services by Patient Type (CPT Codes 92002 – 92014)

• Average Allowed Minutes per E/M Visit by Patient Type (CPT Codes 99201 – 99215)

• Percentage of Glaucoma Patients with Both a Visual Field Examination and SCODI Study Within 90 Days

The report section of the sample shows four possible outcomes for the provider’s data as compared to their peer group:

• Significantly Higher – higher than peer group with statistical significance

• Higher – higher than peer group without statistical significance

• Does Not Exceed – provider data not higher than peer group

• N/A – insufficient data for peer group comparison

THE TAKEAWAY

Whether you were a recipient of a CBR or not, it is important to remember that one of the primary objectives of health care reform is cost containment. These efforts by the federal government and other third party carriers are geared to educate practitioners that normative health care is coming to your specialty and your community. Your data will be compared against at the local, state and national levels. Determinations of providing care that can be identified as “outlier” status will be increasingly easy for carriers to perform. While these programs are educational in nature at this point in time, it is not hard to imagine the aggregated data assembled by carriers over time to be used to determine specific care protocols and corresponding reimbursement models. This is but one of the first steps in the (not so) long road to the long promised outcome based care model we are moving to in the years 2016 – 2018. OM

DR. RUMPAKIS is founder, president and CEO of Practice Resource Management, Inc., a consulting, appraisal and management firm for healthcare professionals. Email him at John@PRMI.com, or visit tinyurl.com/OMcomment to comment on this article.