Diana Riojas, BS, CMC, CMCO, CMOM, CMIS, CMSCS and Gretta Kinsella, CMC, CMOM, CMCO, CMIS, CMSCS

BC Advantage (BCA): When, how and why did you get into health care?
Gretta Kinsella (GK): I have been in the medical field for more than twenty years. I started my career in pharmacy billing with following up on claims while still in high school.
Diana Riojas (DR): I have grown up surrounded by health care but officially entered into health care after receiving my Bachelor's in International business.

BCA: How did you get your first position?
GK: I was working at a pharmacy as a cashier while in high school and showed an interest in learning more about the office processes so they took a chance on me and trained me. Once you get interested in the medical field it is hard to ever leave it. You just want to learn more and more.
DR: I was the daily operations officer for a practice management-consulting firm mainly for a pediatric practice.

BCA: What steps have you taken to learn more about the business of medicine?
GK: I took an 18-month billing and coding training program, and then I maintained and increased my knowledge by attending PMI classes before deciding to become certified in the field.          
DR: I attend seminars, conventions and received the majority of my certifications from PMI

BCA: How have each of your certifications helped you do a better job?
GK: My CMC has helped me demonstrate to doctors that I am not only qualified to code records but I have achieved the necessary certification to support it and that I can audit physicians and show them the importance of documenting correctly. My CMIS has helped me with sending out clean claims to meet insurance requirements so the practice can receive the revenue timely and quickly. It also has assisted in knowing the proper way to appeal claims and communicate with insurance carriers. My CMOM has helped me with the management processes that are required to have a profitable and proficient medical office. Providers rely on their office managers to make the necessary changes to ensure that their staff is properly caring for patients and that the practice is making a profit in doing so as well. CMCO has been the most eye-opening certification class that I have taken to learn the changes in regulations that are affecting practices and to help me implement those changes in our day-to-day processes. It has assisted us in implementing a compliance plan that meets the requirements of HIPAA, OSHA and billing/coding.
DR: My CMOM has helped me to manage the office better in regards to employee management, patients, reports etc. My CMIS has helped me to deal with insurance companies requirements of billing and forms. My CMCO helps me to keep the physician's and the office as a whole stay in compliance in regards to HIPAA, OSHA, billing/coding to better protect everybody from audits. My CMC helps me to better audit my doctors and educate them to strengthen their coding; this will help them even more when ICD-10 is implemented.

BCA: What kind of challenges do you face with regard to compliance?
GK: The regulations change almost daily and staying on top of those changes can be difficult while managing our day-to-day operations as well.
DR: There are always changes happening and keeping up with those changes and implementing them on a timely basis would have to be the most challenging.

BCA: How has having a Compliance Certification helped you in your job?
GK: Having the knowledge and confidence in creating policies/procedures and implementing them to reduce the risk exposure of the practice and business.
DR: I have the ability to create policies and procedures for an office, and complete crucial risk analysis for the office as well.

BCA: Your office was recently audited by Medicaid, tell us what happened.
GK & DR: This story actually started 2 years ago when a major 3rd party carrier group for a pediatric office placed the entire office on a prepayment audit. Every 99214 that was submitted would have to be dropped to paper with documentation sent to them in order to be audited beforehand. 1200 claims of 99214 were denied and we were told that they were 99213's. We fought them and defended the pediatrician's original coding position of a 99214. We were then placed on a prepayment review for 60 days before they took us off and all 1200 claims were paid at a 99214 level.

Now fast forward to June 2011. Just after we have received our CMCO certification we received a letter from the same insurance carrier stating that the sample probe they had conducted on the office late November 2008 with 60 medical records dated from 2006-2008 had been forwarded to the HHSC/OIG. Based on their findings they found that the error rate of again in regards to the 99214's being 99213's the medical records contained and using RATSTATS program used by the OIG resulted in an overpayment of over $102,000 to our office. We were asked to please pay it back ASAP and to have the doctor in question to sign a provider integrity agreement. We once again appealed their decision in regards to the medical records being 99214 and NOT 99213. This time they came back to us with a letter of changing the amount of the recoupment money to just over $42,000. Once again we told them "NO" in a nice political way and proceeded to have the extrapolation thrown out. Finally in early August we received a letter from the carrier stating that because of the low error rate they have decided to waive the extrapolation and direct overpayment. The Pediatric office ended up winning and not having to pay a single penny to the insurance carrier or on attorney fees.

BCA: Anything else you would like to share about the importance of training and knowing the rules or standing up for the practice in an audit?
GK & DR: For Practice managers and coders always, always go to somebody who has a certification with years of experience and can give you advice so you can build on it for your own endeavors. Never give in to an insurance carrier, always fight for your doctors and be their champion. 

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