The pMD Blog

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pMD Blog...

where we cover interesting and relevant news, insights, events, and more related to the health care industry and pMD. Most importantly, this blog is a fun, engaging way to learn about developments in an ever-changing field that is heavily influenced by technology.


Here's The Latest in Health Care:


• In a recent study by Cigna, researchers found that patients who are diagnosed with a behavioral health condition and receive outpatient treatment have fewer visits to the emergency department or readmissions to an inpatient facility. This results in a lower cost for care per person per year.  Read More

• Nearly one in 10 children in the U.S. that are eligible to be vaccinated have received their first dose of the Pfizer COVID-19 vaccine. Children who received their first shot this week and their second three weeks later will be fully vaccinated by the Christmas holiday.  Read More

• This year marks the fifth consecutive year that the rate for improper payment for Medicare fee-for-service has been below the 10 percent threshold. This represents considerable progress toward a goal to protect CMS programs for future generations.  Read More

• According to a recent report, one of several findings surrounding home health care includes the fact that only 34 percent of hospitalized patients are sent to formal post-acute care settings, such as skilled nursing facilities. The rest are either initially sent home or to a retirement or assisted living community, contributing to higher hospital re-admissions.  Read More

Every Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news. Brought to you by pMD, innovators in charge capture, medical billing revenue cycle management, telehealthsecure messaging, clinical communication, and care navigation software.

Here's The Latest in Health Care:


Failing to support the acuity of the medical service rendered with coding and documentation is the number one reason payers deny a hospital claim over a coding issue, according to a new report. Other top causes for denials include if the procedure code is inconsistent with the modifier used or a required modifier is missing, the diagnosis is invalid for the date or dates of service documented, the diagnosis is inconsistent with the procedure, or the diagnosis was not covered at all.  Read More

Nearly one-third of older U.S. adults visit at least five different doctors each year, reflecting the growing role of specialists in Americans' health care according to a new study. On average, beneficiaries saw a 34% increase in the number of specialists they visited each year, while the proportion of patients seeing five or more doctors rose from about 18% in 2000 to 30% in 2019.  Read More

Providers are having a difficult time billing for services related to COVID-19, with 40 percent of charges for coronavirus-related care initially winding up as claim denials in the first 10 months of 2021, according to a recent analysis of more than $100 billion worth of denials and $2.5 billion in audited claims.  Read More

The Centers for Medicare & Medicaid Services has released the final physician fee schedule rule that sets out payment rates for 2022. In addition to including several provisions that aim to expand flexibility for telehealth reimbursement for mental health, including removing geographic restrictions, the rule will also let the 3.75% temporary pay bump given to physicians for 2021 expire.  Read More

Each Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news. Brought to you by pMD, innovators in charge capture, medical billing revenue cycle management, telehealthsecure messaging, clinical communication, and care navigation software.

Here's The Latest in Health Care:


Hospital revenue cycle transformation is needed to elevate poor enterprise performance as a result of the COVID-19 pandemic, according to experts from healthcare management consulting firm Kaufman Hall. Three-quarters of hospital and health system leaders said their organization experienced “adverse revenue cycle impacts” during the pandemic, including a higher percentage of Medicaid patients and increased rates of denials.  Read More

While nearly 16% of doctors' visits by seniors were done remotely, either by phone or online over the past two years, the rural elderly appear to be behind the curve, according to a new analysis of telehealth visits billed to Medicare. One-third of rural older adults had at least one virtual visit in 2020, compared with nearly half of seniors in suburban and urban areas.  Read More

The majority of Americans don’t fully understand the information their provider tells them, leading them to consult third-party resources like the internet, a new survey found. In fact, according to the survey, three in four Americans leave the doctor confused and dissatisfied for reasons that include disappointment in the level of Q&A they have with their doctor, confusion about their health, and a need to do more research.  Read More

More physicians are migrating to hospital employment, changing the traditional physician-ownership models of ASCs. According to ASC leaders, there are a number of contributing factors, including the fear of declining reimbursements combined with the complexity of new payment models. Health care has become a "big cap" business requiring market scale, data analytics, and risk management, concepts that small practices are worried they can’t handle on their ownRead More

Each Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news. Brought to you by pMD, innovators in charge capture, medical billing revenue cycle management, telehealthsecure messaging, clinical communication, and care navigation software.
Increasing medical practice revenue


As health care organizations in the U.S. move towards electronic systems to manage their patient records, data collection and analysis on health care information has become easier for entities like the Centers for Medicare and Medicaid Services (CMS). As a result of this, trends in patient outcomes and patient health history can provide useful information. This has given way to a new format of hospital reimbursement in health care, which is called value-based care.

VALUE-BASED CARE AND ALTERNATIVE PAYMENT MODELS


Value-based care is a broad term for a reimbursement model for health care organizations (HCOs) in which CMS or other insurance institutions will reimburse based on the quality of care provided and the quality of patient outcomes. This means that providing efficient and quality care to a patient will result in a higher reimbursement for the HCO, while inefficient care will result in a lower reimbursement to the organization. This differs from the traditional fee-for-service model, where providers are reimbursed based on the service provided to a patient, regardless of quality of care or outcome.

One way that CMS has begun to implement value-based care models in the U.S. is by offering certain HCOs the opportunity to participate in Alternative Payment Models (APMs), which is their version of value-based care. There are nearly 100 APMs offered by CMS that organizations can participate in, each of which has different participation requirements and different quality measures by which patient outcomes are measured. The Bundled Payment for Care Improvement (BPCI) Advanced model is a great example of an APM.

BUNDLED PAYMENT FOR CARE IMPROVEMENT (BPCI) ADVANCED MODEL


The BPCI Advanced model is just one example of a value-based payment model, and it’s one that pMD can largely accommodate today. The quality measures tracked by this payment model are: 

1. Unexpected hospital readmission for the patient in question within 30 days of discharge
2. Existence of an Advanced Care Plan
3. Quality of care based on a list of 26 CMS-defined Patient Safety Indicators  

How are these quality measures reported and tracked? With HCOs' profits on the line, most would not want to participate in a reimbursement model that could lose them money if they’re unprepared. Fortunately, with the BPCI Advanced model, and many of the other models offered by CMS, these quality measures can be completely tracked through electronic means, providing a more streamlined way to submit that information to CMS. The additional work required here, however, would be the time it takes to complete some advanced care planning with your patients, a practice that may not have been standard but has been shown in data to have a positive impact on patient outcomes in health care.

Not only does pMD have the capability to accurately submit claims electronically but we also provide the tools to help organizations better navigate patient care. Our comprehensive platform offers customizations to accommodate the growing needs of practices participating in alternative payments models. pMD’s functionality is constantly evolving to support customers looking to participate in value-based care payment models, improve patient outcomes, and maximize reimbursement.

 

To find out more about pMD's suite of products, which includes our charge capture and MIPS registrybilling servicestelehealthsecure messagingclinical communication, and care navigation software and services, please contact pMD.
Increasing medical practice revenue


Medical coding is a key component of the claim cycle and is necessary for claim reimbursement. Inaccurate coding can affect your practice in many ways, which can lead to missed revenue, potential overpayments, and allegations of abusing reimbursement policies. Inaccurate coding may also result in staffing challenges as the demands of follow-up on claims denials increase. In this blog post, we’ll focus on ways that practices can improve medical coding accuracy and avoid the consequences of inaccurate coding.

FIND AREAS OF OPPORTUNITY


Contracting with a consulting or auditing organization to perform an independent third-party audit is a great starting point when determining where your practice should focus in order to improve medical coding quality and accuracy. Not only is your practice being proactive, but audit findings can guide you to the areas that need the most attention and help you avoid unknowingly committing abuse of reimbursement policies or missing out on valuable revenue opportunities. After each audit, consultants or auditors should educate the practice regarding areas in which to improve, and subsequent audits should ensure that previously identified areas of struggle have been corrected or addressed. Practice size, patient type, and regulatory changes should all be considered when determining how frequently to perform audits. A consultant can help you determine what cadence and sample size are best for your practice, but at minimum, the Office of Inspector General (OIG) recommends that at least 5 patient charts per provider per year are reviewed. 

STEP UP YOUR DOCUMENTATION GAME


Documentation is perhaps one of the easiest ways to improve medical coding accuracy. The more detail a provider includes in his or her documentation, the higher the reimbursement. When documenting your visit with the patient, it is important to remember that reimbursement is based on what exists in the medical record. If your practice struggles with documentation, consulting with a Clinical Documentation Improvement (CDI) Specialist could be insightful and helpful. The CDI Specialist can review your process and guide your practice through proper documentation to help improve coding as well as obtain maximum (and compliant) reimbursement. 

PARTNER WITH SUPERSTAR CODERS


Coding rules and regulations change frequently to adapt to the needs of health care. Medical coders spend years perfecting their expertise by gaining experience and obtaining certifications, hence why partnering with coding experts is certainly one way to improve coding accuracy and maximize reimbursement. Coders can help to fill documentation gaps and provide valuable feedback and education to providers. When hiring or partnering with a medical coding company, consider the following:

1) Resources to meet your staffing needs
2) Certifications - there are many types, including specialty-specific ones 
3) Number of years of experience
4) Proven track record of success including case studies and testimonials from former and current clients or employers

While there are many solutions that exist, it is important to find the right strategy for your team and implement best practices to avoid adverse effects of inaccurate coding. pMD’s team of billing experts is here to help you every step of the way so that you can focus on what matters most. Leave the rest to us!

To find out more about pMD's suite of products, which includes our charge capture and MIPS registrybilling servicestelehealthsecure messagingclinical communication, and care navigation software and services, please contact pMD.

Here's The Latest in Health Care:


Hospital officials say Anthem Blue Cross, the country's second-biggest health insurance company, is behind on billions of dollars in payments owed to hospitals and doctors. Disputes between insurers and hospitals are nothing new, but this fight sticks more patients in the middle, worried they'll have to pay unresolved claims.  Read More

In the latest Medicare Physician Fee Schedule, CMS proposed for the first time a set of charge codes for remote therapeutic monitoring. The inclusion of these codes suggests that transformations in digital health policy initiated in response to COVID-19 are beginning to have some permanence.  Read More

The difference between clean claims and initial claims denials is a major key performance indicator (KPI) that hospitals track, and according to a new survey, nearly 80 percent of hospitals are measuring the difference in the rates. But this KPI may not be the best indicator of revenue cycle health according to the survey authors.  Read More

As COVID-19 continues to overwhelm providers across the country, cybercriminals are increasingly targeting smaller facilities with sophisticated healthcare ransomware attacks that cause EHR downtime and care disruptions. A recent study showed that hackers are turning to outpatient clinics, smaller hospitals, and business associates to target their attacks at unassuming victimsRead More

Each Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news. Brought to you by pMD, innovators in charge capture, medical billing revenue cycle management, telehealthsecure messaging, clinical communication, and care navigation software.
Increasing medical practice revenue


Patient adherence within the medical community can mean different things to different providers depending on the specialty. For patients that require therapeutic drug monitoring, adherence to medication can mean the difference between wellness and illness. An estimated 30 to 50 percent of U.S adults are not adherent to long-term medications, so one can only imagine the difficulties that brings for both patients and providers. 

What is therapeutic drug monitoring?


In the simplest of terms, therapeutic drug monitoring (TDM) is a form of testing that tells a provider the concentration of certain medications in a patient’s blood and what bodily systems it may be impacting. TDM is used in a variety of specialties to include, but is not limited to, cardiology, internal medicine, neurology, psychiatry, pulmonology, nephrology, rheumatology, gastroenterology, and many others. 

A patient is first deemed a good candidate for a medication requiring TDM based on several factors such as age, weight, current organ function, current medication regimen, or even results from pharmacogenomic testing. Once the medication is prescribed, a predetermined length of time passes before the patient is required to undergo routine laboratory work to test for current medication concentration along with a clinical assessment to rule out signs or symptoms of side effects. Providers then use their clinical judgment to determine if the medication must be adjusted, which then requires the patient to return again at a predetermined time for ongoing assessments. 

The importance of therapeutic drug monitoring


One may ask themselves: “Why does it even matter? The medication works or it doesn’t.” Certain medications have a narrow therapeutic window which can cause concern for patient wellness if medication is taken outside of that window. Providers use TDM to determine important factors such as non-adherence, subtherapeutic levels, and toxicity. The ability to identify if the patient is adherent to prescribed therapies as well as identifying the need to adjust medications to prevent patient injury is important in the long-term wellness of the patient. 

Studies have shown that patients undergoing TDM and who were adherent to medication protocol experienced fewer adverse effects, improved their ability to meet their own daily needs, and lowered overall medical costs as a result of fewer hospital admissions. 

The problem is that as medical practices grow, the ability to track a patient’s needs during TDM can become convoluted. Providers and medical staff must check when each patient’s labs are completed, document the results, communicate the need for medication changes to the patient, and repeat these steps for every designated time period. What would be the best practice for tracking TDM patients? And communicating with them about their missed appointments or the dangers associated with missing TDM steps such as laboratory work or patient assessments? The ramifications of non-adherence to medications coupled with the endless possibilities of communication errors can result in an increased risk of patient injury or even death. Some long-term effects of unmonitored medications can result in cardiovascular disease, kidney disease, thyroid disease, liver disease, and other chronic or life-threatening conditions. 

An easier way to communicate and track patient needs


At pMD, we are dedicated to making life easier for providers and patients alike by helping decrease communication errors, increase adherence, and improve patient outcomes. For each new customer, pMD takes the needs of the practice to heart and has the ability to build out custom fields for patient populations such as those who may require therapeutic drug monitoring, for example. In addition to this simplified way of keeping track of patient needs, pMD offers HIPAA-compliant communication with patients. While therapeutic drug monitoring may be associated with certain patient populations, pMD is dedicated to helping a variety of different patient populations and specialties.

 
To find out more about pMD's suite of products, which includes our charge capture and MIPS registrybilling servicestelehealthsecure messagingclinical communication, and care navigation software and services, please contact pMD.

Here's The Latest in Health Care:


Traditionally, healthcare data has centered around clinicians and institutions that largely controlled patient interaction. Lately, however, there has been a shift to consumer-centered systems. This is enabling patients to interact with health professionals and get involved in their own care, leading to greater engagement, improved outcomes and increased satisfaction.  Read More

CMS will begin to reprocess claims for outpatient clinic visit services provided at excepted off-campus provider-based departments, following a reinstated site-neutral payment policy. The agency will start processing the necessary claims, with no action needed on the provider side, by November 1, 2021.  Read More

The Lown Institute, a nonpartisan healthcare think tank, recently unveiled their social responsibility hospital rankings, which is based on 54 metrics across three main categories: equity, value and outcomes. Among the metrics are inclusivity, pay equity, avoiding overuse and clinical outcomes, as well as cost efficiency, a new metric that evaluates how well hospitals achieve low mortality rates at a low cost.  Read More

Sicker patients, fewer outpatient visits, and higher expenses for labor, drugs, and supplies will continue to damage the financial health of hospitals and health systems throughout 2021, says a new analysis released today by the American Hospital Association (AHA). Hospitals nationwide are expected to lose about $54 billion in net income over the course of the yearRead More

Each Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news. Brought to you by pMD, innovators in charge capture, medical billing revenue cycle management, telehealthsecure messaging, clinical communication, and care navigation software.
Increasing medical practice revenue


Claim denials cost providers millions of dollars each year; hard-earned money that could be allocated to more deserving services. We find that many practices do not have the time or resources to work through these denials and therefore those charges are written off and the practice loses out on revenue. The good news is we’re here to help mitigate that lost revenue, which starts by identifying what those common denials are.

Service Not Covered


These are words a provider never wants to hear but is a common denial that practices often receive. This denial occurs when the service is rendered prior to verifying the patient’s benefits and cross-referencing those benefits with the payer’s LCDs (Local Coverage Documents / Determinations) and Articles. These documents outline whether or not a particular item or service is covered on an intermediary or carrier-wide basis. Additionally, each governmental payer and private health plan do not share the same policies and also do not necessarily publish those guidelines where they are easily accessible. With a little extra time and research as well as implementing a process that will keep everyone up-to-date with the ever-changing guidelines, practices can easily avoid such a denial.

Missing Information


If a claim lacks even the slightest piece of pertinent information, you’ll find yourself with a denial. These denials can range from missing data in the fundamental fields such as date of birth, address, policy number, date of the accident or admission, lack of explanation of benefits from the primary payer, as well as failing to code to the highest level of specificity. These denials can be avoided by utilizing smart software that verifies all the information necessary to a claim prior to it being submitted to the payer.

Coding Errors


Providers are not trained to be coders so why is it that they pay the price for coding errors? Payers expect all submitted charges to have been scrubbed appropriately and follow all coding guidelines. Minor errors such as an ICD-10 code with too few digits, services that fail to include all applicable codes, and codes that do not align with the correct place of service can all trigger a denial from the payer. The idea of memorizing coding guidelines sounds like one more laborious task but leveraging a coding team and integrating National Correct Coding Initiative (NCCI) triggers within your practice's software provides a proactive approach in preventing these denials.

Duplicate Claim or Service


A service that is resubmitted for an encounter on the same date, by the same provider, for the same beneficiary, or for the same service will be denied as a duplicate. Sounds reasonable enough but the key to these denials is determining if the charge is in fact a duplicate claim or if the intent was to submit a corrected claim for another denial. It’s easy to disregard a duplicate denial as it suggests that the claim has already been adjudicated but you’ll find yourself leaving money on the table if you do not closely monitor these denials for accuracy. Each payer has particular protocols for which they are willing to accept corrected claims. If you fail to follow these guidelines, it will result in a denial for a duplicate claim in addition to the original denial. You’ll want to be sure that the true denial is addressed accordingly and you have received payment before you file away the duplicate denial. 

Limit For Timely Filing Has Expired


Each denial that you receive will ultimately result in a payment turnaround lag. It also can lead to a lack of payment if not addressed within a timely manner. By ensuring you submit your claims within the payer’s timely filing guidelines, you can easily avoid this denial. That sounds simple enough but it would also require you to be aware of every single one of those guidelines. Unfortunately, there is not a universal policy and can vary from payer to payer. Some accept charges up to 365 days from the date of service and others as little as 90 days post-service date. Submitting claims electronically can help expedite your submission and also provide you with acknowledgment reports should you find yourself having to produce supporting documentation that the claim was filed within the payer’s requirements. 

Additional Ways to Prevent Denials


Let’s face it, some denials are inevitable. Why not leverage the denials that you’ve already received to create predictive logic in your software that can flag potential denials in the future. By analyzing denial trends and also collecting supporting documentation in advance, you can eliminate denials altogether!

Once you have identified the denial trend and implemented a process to avoid future denials, take it to the next level. After you have established that your documentation has substantiated your historical billing, initiate a contract with the payer to eliminate future requirements to have to provide supporting medical records. An expert team can help support that negotiation and also facilitate the management of tracking, analyzing, and reporting on these trends to get ahead of them. 

With all that said, how do medical denials impact your patients? Your top priority is maintaining a good relationship with your patients, and you can still do so while preventing revenue loss. It helps to have an expert on your side that is conversant with the provisions of these payers. They can navigate those denials, advocate on behalf of the patient, and alleviate the burden on both the patient and the practice. 

Our experienced team of experts is here to support you through all these challenges. Let us take on reducing your claim denials and increasing your practice revenue so that you can focus on what truly matters most - your patients.

To find out more about pMD's suite of products, which includes our charge capture and MIPS registrybilling servicestelehealthsecure messagingclinical communication, and care navigation software and services, please contact pMD.
Increasing medical practice revenue


Last month, we took a look at three ways to increase medical practice revenue. Today, we’re going to look at a few more!

We’re nearly three-quarters of the way through 2021, and though we’ve been able to adapt to many of the ways the COVID-19 pandemic has altered the medical landscape, we are not out of the woods yet, and neither is your practice revenue

PATIENT OUTREACH:

A recent study found that one in five adults delayed seeking medical care due to the pandemic. There are multiple factors that could have contributed to this: apprehension from being exposed to the virus, financial challenges, and difficulties in accessing care.

You may have patients who, despite potentially having conditions that need treatment, are anxious about resuming their usual medical care due to fears about their safety or even concerns over the availability of appointments.

Establishing an open line of communication with your patients, along with keeping them informed of their care options, will help reassure patients that they are your top priority. Make patients aware of any available appointment openings, how they can utilize telehealth, as well as the precautionary measures your practice is currently taking to keep them safe. Give them the opportunity to reach out to your staff to discuss their current financial situation, and what they can expect if they choose to resume care. A great patient experience can lead to stronger patient retention as well as a higher likelihood of on-time payments. 

CLAIMS INVESTIGATION:

As discussed in our previous blog, you don’t want to sit on unpaid claims from insurance carriers. Remember to diligently follow up on any denials, and make sure bills are submitted by your billing team daily. A faster turnaround leads to faster payment!

Much of your revenue is going to come from insurance payments, so it’s essential to ensure that you and your team are staying on top of it. Experts recommend having staff members take ownership over outreach with insurance carriers they have experience working with so that it’s easier to delegate claims investigation and ensure that the workflow is organized efficiently. Don’t just have them re-submit a rejected claim to an automated system. You’ll want to confirm what the carrier needs from you to ensure that this time, your submission will be accepted.

The last thing you’d want is a rejection to be accepted by your practice at face value and to have that total forwarded to your patient. Studies have shown that unreasonably high bills can cause patients to distrust their medical professionals, even if the practice had nothing to do with allocating the bill itself. Practices benefit more from large insurance sums than from expecting their patients to cover the total alone, plus it prevents patients from feeling that the practice isn’t looking out for their best interests. 

ONLINE COLLECTION

Modern patients want modern solutions. Your average American already uses their phone to order rides and meals, as well as to pay their bills. They want convenience, so why not make paying their copays and medical bills just as easy? 

Although older patients may be more comfortable paying an individual directly or even sending a check, younger generations are more accustomed to making all of their payments online. Giving patients the ability to make payments more quickly, and in a format that they trust, provides a faster and more instant payment turnaround for your practice.

A payment platform also gives patients the ability to confirm their current balance with their own eyes and provides immediate verification that their payment has been processed. Setting up payment plans then becomes simpler and easily automated. Instead of navigating through transferred calls and mailed paperwork, patients have the control to handle their medical finances the same way they handle all their other expenses.

pMD’s billing service has found ways to streamline and enhance the billing and payment workflow, giving providers and patients more control over their respective processes. Contact us today and learn how we can help you improve practice revenue!

To find out more about pMD's suite of products, which includes our charge capture and MIPS registrybilling servicestelehealthsecure messagingclinical communication, and care navigation software and services, please contact pMD.