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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.

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Finances and the revenue cycle can be a high source of stress for providers, who let’s be honest, would much rather focus on patient care. However, effectively managing a practice's revenue is crucial to actually being able to continue to provide that care. One of the most unpredictable phases of the revenue cycle is collecting patient responsibility, which often results from the high variance in payment methods as well as hesitation to pay due to a lack of understanding of insurance systems. Simply put, many patients don’t know what they owe and why.

WHY IS COLLECTING PATIENT PAYMENTS SO HARD?

According to the American Association of Family Physicians, only 14% of adults understand key components of their insurance plans. This confusion and uncertainty can often make it difficult to determine a patient’s financial responsibility at the time of a visit, leading to even more frustration when they get a bill in the mail months later that they don’t understand. Estimation tools and insurance cards can help ease this uncertainty or to point a practice in the right direction, but ultimately most patients end up in the dark when it comes to what they will owe in the end. 

Traditionally, many practices end up providing services for free, collecting a small insurance co-pay, or sometimes not even that, and then opting to bill the patient later, after collecting from insurance first. The problem is the process of settling with and collecting from insurance companies can take days, weeks, or even months and by that time patients are far less likely to pay for bills they receive long after services rendered. In fact, more than 60% of patients surveyed by InstaMed reported they would “consider switching providers for a better healthcare payment experience,” which includes upfront patient responsibility, eligibility, and the ability to pay with their preferred payment methods. 

With this in mind, it’s hard to believe less than 25% of physician practices have an eligibility and estimation tool in place to assist their practices in maximizing revenue, according to Healthcare Finance News.  By providing real-time patient responsibility estimates, providers can increase patient confidence and are more likely to collect the full amount they are owed for their services. Without an eligibility solution in place, practices could potentially be missing out on between 30-50% of their patient revenue. 

ADAPTING TO THE NEXT GENERATION OF PATIENTS

Speed and transparency make a huge difference when it comes to collecting patient payments. Giving your patients the tools to make the process as simple as possible is key to not only collecting but collecting quickly with high patient satisfaction. Many practices still rely on mailed statements and/or in-person payments, such as cash, check, or credit card, which can be a major hindrance, especially when it comes to younger generations. 

Gen Z, which are those born between 1995 and 2012, is expected to account for an estimated 61 million new employees in the global workforce in the next decade. Why is this important? Well, the majority of Gen Z have never lived without the internet, smartphones, and immediate access to information and products. With an influx of Gen Z patients, the expectation is that practices make it easy to receive and pay for care. If it’s not, they may seek care elsewhere. 

It’s much easier to collect payments when the patient is standing in front of you, but even if they’re not, the quicker a practice requests payment, the more likely patients are to pay it. Recent trends in expected payment options have shown nearly 50% of patients would prefer to pay their medical bills using contactless or paperless payment options. Practices using paper statements introduce significant lag into their collection systems by relying on mail carriers and printing/packing services. Recent improvements in payment processors and the technology they offer have made it possible to send statements and payment requests in real-time to speed up collections and boost patient satisfaction and confidence. 

EVERYTHING SHOULD BE IN ONE PLACE

The last part of the equation is making sure everyone in the practice is on the same page regarding patients’ financial status. The fewer systems involved, the less room for error and inefficiency. From patient intake to collecting payments, it’s important to be able to do everything in one place without having to log into multiple systems to piece together information.

 

If you are interested in learning more about pMD’s billing and revenue cycle management services, please contact us here or give us a call at 800-587-4989 x2. We’d love to hear from you!

 

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


Claim denied. Ugh! These are two words that make all those involved in the health care revenue cycle cringe. Unfortunately, claim denials are very common, costly, and time-consuming to correct. However, there are strategies to avoid them, with the potential to significantly increase your bottom line and decrease your revenue-related headaches. We’re going to talk about one of those strategies here — real-time eligibility. 

WHY ARE MY CLAIMS BEING DENIED?

Eligibility verification is one of the first phases in the revenue cycle and by far the most significant. Did you know eligibility issues are one of the top five reasons claims deny? In fact,  nearly 24% of claims submitted are denied for eligibility and registration issues, such as the patient not being eligible for medical benefits on the date of service, or having incorrect demographic information, like date of birth or a misspelled name. 

The eligibility verification process is directly linked to claim denials which can have a variety of unwanted consequences. This includes a hike in the number of days in A/R, an escalation in write-off rates, a standstill of cash flow, inflated costs to collect, and most importantly, delays in a patients' access to treatment. The process of verifying eligibility needs to be both efficient and accurate in order to determine the responsibilities of both the payer and the patient.

HOW DO I MAKE SURE MY CLAIMS AREN’T DENIED?

Most claim denials are avoidable, in fact, 90% of them could be avoided. Research also shows that of those denied claims, approximately 60% of claims are recoverable, meaning they can be corrected and resubmitted for reimbursement. 

This sounds pretty good, right? Well, the reality is that a whopping 65% of denied claims are never reworked, which translates to a huge loss in revenue. The remaining claims that are reworked can be a drain on resources when factoring in both time and overhead costs. The average cost to correct and resubmit a denied claim can range anywhere from $30 - $125 per claim.

By implementing the right tools and processes, such as checking real-time eligibility, the likelihood of having your claims denied decreases significantly. By simply using real-time eligibility tools, you’ll be able to increase the number of  “clean” or error-free claims submitted,  tackling a number of the top reasons claims are denied, such as eligibility, no authorization, or being covered by another insurance plan.

WHAT IS REAL-TIME ELIGIBILITY?

But what exactly is real-time eligibility, and how do I use it to my advantage?

Real-time eligibility is a software tool that allows medical staff to electronically confirm a patient’s insurance coverage by interfacing directly with the insurance carriers. This instant eligibility check provides an up-to-date overview of the patient’s coverage and plan benefits. Real-time eligibility can answer important questions such as if the insurance policy is active, the start and end dates of a policy, deductible amounts, copay coverage, and if prior authorization is required. Verification checks can be done at the time of the patient’s appointment, or even prior, which not only saves both the staff and patient time during check-in but also provides a clear understanding of both the provider and patients’ responsibilities.

Real-time eligibility benefits all those involved in the revenue cycle management process. For example, the amount of time staff spends checking and verifying a patient’s coverage is reduced significantly, as it eliminates back and forth phone calls, and the need to check multiple systems in order to verify coverage. Additionally, verifications are saved to the patient’s record, which provides an audit trail and proof of insurance coverage. Plus, it makes it much easier to submit clean, error-free claims, which facilitates faster payment and improves cash flow, which leads to increased provider satisfaction. Let’s not forget about the most important part of the revenue cycle, the patient. Being able to communicate to the patient their financial responsibility prior to, or at the time of service, makes for a much-improved patient experience.

Claim denials are preventable when identified and addressed early in the revenue cycle process. By implementing real-time eligibility, you can decrease the burden of claim denials, and in turn, enhance revenue, improve the overall patient experience, and let the provider focus on what matters most — patient care.

 

If you are interested in learning more about pMD’s billing and revenue cycle management services, please contact us here or give us a call at 800-587-4989 x2. We’d love to hear from you!

 

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


Welcome to the "Biller’s Corner" of the pMD blog, your trusted source for updates, tips, and tricks provided by seasoned medical billing and coding experts!

Medical coding is often a moving target, especially during a pandemic. But have no fear, we’re here to provide guidance on some recent coding updates you need to know about!

NEW COVID-19 VACCINATION CODE ALERT

Speaking of the pandemic, the AMA recently released the CPT® code 91303 for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative-free, 5×1010 viral particles/0.5mL dosage, for intramuscular use.

Here’s what you need to know:


* This is the code used for the one-dose COVID-19 vaccine developed by Janssen Pharmaceutica, a division of Johnson & Johnson.


* It should be used in conjunction with the CPT code 0031A, Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative-free, 5×1010 viral particles/0.5mL dosage, single dose.


AMA PROVIDES ADDITIONAL CLARITY ON THE UPDATED E/M CODE SET

Another hot topic this year has been the significant updates to E/M office codes (99201-99215). The primary intention behind the changes is to reduce the administrative burden of unnecessary documentation, in turn, allowing for more time to interact with patients. While the intention is great, there has been a lot of confusion surrounding the revisions made to this code set, and many physicians have reported that the ambiguity of the new revisions is actually leading to additional time spent on documenting. This is obviously the opposite of what they were going for, so the AMA is acting on that feedback and has released the following revisions, retroactive to January 1, 2021.

TIME-BASED BILLING

For time-based billing, you should not account the following:


* Performance of other services when reported separately


* Travel time


* Teaching that is not required for the management of the specific patients' care


Also, remember Medicare and private payers’ policies can differ when it comes to reporting prolonged services for time-based billing. Although the AMA has established the CPT 99417,  Medicare has assigned a status indicator of “I” for this code which denotes the code as invalid. Instead, Medicare will accept HCPCS code G2212 when reporting 15 minutes of prolonged care, performed on the same encounter as E/M codes 99205 and 99215. When billing for either code, be sure that it is listed separately in addition to a level 5 office/outpatient E/M service.

MEDICAL DECISION MAKING

When it comes to medical decision making (MDM), you should account for tests that are analyzed as part of MDM and are not reported separately when interpreting the study. These may be counted as ordered or reviewed when selecting an MDM level.  When determining the complexity of problems and the number of problems addressed, also consider the following:


* If the presenting symptoms are likely to represent a highly morbid condition, this may “drive” MDM even when the ultimate diagnosis is not highly morbid. Multiple low severity conditions may equate to a higher risk level due to interaction.


* When determining data reviewed and analyzed, pulse oximetry is not considered a test.


* When considering data elements reviewed, a combination of three data elements can be counted by reporting a unique test ordered, plus a note reviewed and an independent historian. However, it does not require each item type or category to be represented.


* Ordering a test may include those considered, but not selected after shared decision making due to patient health risk or a discussion to forego further testing due to lack of medical necessity.


UNDERSTANDING THE KEY TERMINOLOGY

The AMA has also provided clearer instructions to interpret the definitions that make up the elements of MDM. Understanding the following terms as they are laid out by the AMA is crucial:


* Analyzed: Tests ordered are presumed to be analyzed when the results are reported. Therefore, when they are ordered during an encounter, they are counted in that encounter. Tests that are ordered outside of an encounter may be counted in the encounter in which they are analyzed.


* Discussion:  Discussion requires an interactive exchange. The exchange must be direct and not through intermediaries (eg, clinical staff or trainees). The discussion can be asynchronous and occur on a later date following the encounter but must be completed within a short time period (eg, within a day or two).


* Independent Historian: When collecting the history, it does not need to be obtained in person but does need to be obtained directly from the historian providing the information.


* Risk: The term “risk” as used in these definitions relates to risk from the condition. While condition risk and management risk may often correlate, the risk from the condition is distinct from the risk of the management.


* Surgery (minor or major): The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.” These terms are not defined by a surgical package classification. Be advised that CPT guidelines indicate that it is the provider's clinical determination whether surgery is considered major or minor and is not dictated by global days. However, if the surgery occurs in an office setting, you will have a hard time justifying it as a major surgery. Major surgeries will most often require the use of an operating room.


* Surgery (elective or emergency): Elective procedures and emergent or urgent procedures describe the timing of a procedure as it relates to the patient’s condition. An elective procedure is typically planned in advance and scheduled, while an emergent procedure is typically performed immediately or with minimal delay to allow for patient stabilization. Both elective and emergent procedures may be minor or major procedures. 


* Surgery (risk factors): Risk factors are those that are relevant to the patient and procedure. Evidence-based risk calculators may be used, but are not required, in assessing patient and procedure risk.


A full list of revisions can be found on the AMA website. Plus, be on the lookout for even more revisions that will become effective in 2023. 

Make sure to check back in soon for more billing and coding updates! And if you are interested in learning more about pMD’s billing and revenue cycle management services, please contact us here or give us a call at 800-587-4989 x2. We’d love to hear from you! 


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



Information technology is supposed to make work-life more efficient, accurate, and effective. The promise to eliminate duplication of effort and minimize fat-finger typographic errors is the core reason for adopting much of the IT used in the modern medical office. Nothing delivers on these promises more directly than establishing interfaces among the various computer systems in the health care delivery universe.

SHOULD YOU HAVE TO PAY FOR AN INTERFACE?

At pMD, our stated raison d'être is to save patient lives by reducing the risk of medical errors stemming from miscommunication and non-communication resulting in care gaps.  pMD was created to improve efficiency, accuracy, and information exchange among caregivers and patients.  Since interfacing is so integral and critical to achieving this goal, pMD has never charged our clients for an interface.  

When dining at a restaurant, you are paying for the food, but you are not charged extra for utensils or a plate.  When investing in a system to improve business efficiency and accuracy, getting quality data into and out of it should not cost extra.  This principle is at the core of the pMD approach to interfacing with other systems, including hospitals, practice management, answering services, and billing and revenue cycle management (RCM) services.  

Unfortunately, most other participants in the industry have a different view on the subject.  While pMD does not charge for interfaces, the reality is that most Practice Management (PM) System vendors do charge thousands of dollars for them.  Some hospitals and health systems also charge for data feeds to private practices as well, although can vary with the practice’s relationship with the hospital.

INTEROPERABILITY IS IN OUR DNA

Our commitment to core principles drove the way we designed our interfacing technology and continues to drive our methodology.  While many players in the industry are unwilling or unable to modify the format of the data they send or expect to receive, pMD has developed a system that allows us to be very flexible within the HL7 standard for interfacing.  Not only do we not charge providers, but we will flex to suit the needs of the systems we are exchanging data with.  

We have a huge existing and growing library of interfaces to a large number of systems that allow us to implement many interfaces with off-the-shelf modules quickly.  Our approach allows us to easily make adjustments to those existing interfaces for practices with unique requirements and workflows.  We’re also not limited to the systems we’re currently interfaced, we can adapt existing packages to quickly develop new interfaces with systems we have not previously encountered.  

pMD can process data for new and existing office and hospital patients, appointments scheduled in a practice management system, and can of course send charges in pMD back to the PM or RCM systems, customized to their unique requirements. The best part of it all, it is all included in the complete service that pMD prides itself on.

If you are interested in learning more about our interfacing capabilities, please contact us here or give us a call at 800-587-4989 x2. We’d love to hear from you!

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


 

At the time of writing this blog, Valentine's Day was right around the corner. Love was in the air, teddy bears and chocolates had blossomed all over my Amazon Prime homepage, and a flurry of statistics and fun facts about the holiday had hit my news feed:

*9 million proposals were expected to be made on Valentine's day 
*1 million people were expected to change their relationship status on social media

That’s a lot of commitment!

Recently, at pMD, I’ve been working with physician practices on another area of commitment: who to entrust with their revenue cycle. Health care practitioners rely on their billing teams to send out health insurance claims and patient statements to keep their practices functioning. Practices are heavily dependent on the effectiveness of their revenue cycle to keep their doors open and to track their financial health. When looking at an existing or potential partnership with a billing team, how do you know if it’s the forever commitment or if it’s time to re-evaluate?

Will U B Mine?

Choosing the right billing team can feel a lot like speed dating with potential billing companies, certified coders, and billing specialist candidates. Thirty minutes to an hour-long conversation with multiple candidates to determine if this is the right long-term fit for your group is a huge investment of time but at the same time doesn’t seem like enough. However, most groups are hard-pressed to make a decision quickly for fear that accounts receivable will just back up and incomes halt to a dead stop. When there is urgency and a need, it can be tricky to sort through exactly what you are looking for. At the end of the day, they will all get your insurance claims out the door, right? 

There are three key elements that you can use to evaluate to see if your current or future billing service is the one for you. 

Trust

Do you trust this billing team? Making sure you have communication flowing both ways is key. pMD is built on a passion for communication and that remains a foundational item for us in revenue cycle management. Clear communication helps practices by keeping clinical and administrative teams on the same page with updates, changes, and opportunities for improvement. 

Another element to look for is expertise in the industry, and I don’t just mean the amount of time spent in billing. Health care practices come in all shapes and sizes. There are specialty-specific and regional considerations when it comes to billing claims. Having a partner that understands the intricacies of your practice from the revenue side as well as the clinical side will allow for trust and ultimately help your practice grow. 

Transparency

Do you know where you stand financially? As a practice owner, there shouldn’t be a challenge in getting a report for your data. Knowing where your business is financially is critical to making sure you are hitting the benchmarks and goals you have planned for. Are you able to see where the inefficiencies are in your revenue cycle? Identifying the source of creeping charge lag, the root cause of an increase of a specific denial, or even trends in payment amounts is the first step to set your practice up with a plan to correct it. 

Partnership

Can you count on your billing team to support your goals? Medical billing has a ton of data flowing through the system and your billing team is the closest to that information. Their insight can help identify and propose solutions to address items that are holding you back from your full potential. These are the specialists that can help educate your team on best practices or provide background information on why different elements are important to claims. Your billing service is the team supporting you and your practice and is the one you need to be invested in your success. 

At pMD, we want to see you succeed! Let’s chat more about our billing service offerings and what we can do to help you.


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


I’ve worked in health care for many years, and while providers face their fair share of challenges, there’s one question that I’ve noticed almost always bubbles to the top - who do I ask about coding questions? This can be especially distracting as they attempt to focus their efforts on providing the best medical care.

Why Coding is So Difficult

Coding appears to be a thorn in everyone’s side. Why is that? Well, imagine having to enter codes on patients 30+ times a day! Currently, to determine whether you’ve made the correct E&M (evaluation and management) code selection, providers must successfully meet each criterion of the 1997 Documentation Guidelines for E&M Services. Yes, you read that correctly, 1997! 

Let’s take a look at charge code 99213 as an example. While this may seem like a straight-forward, low-level subsequent visit, think again! To correctly select this code, you need to meet two of the following three requirements: 1) an expanded problem-focused history; 2) an expanded problem-focused examination; and/or 3) medical decision-making of low complexity. But, that’s not all. Now answer the following question; how do you define and determine expanded and low complexity? Each of the previously required components is broken down even further into several categories and elements that need to be considered.

As you can see there are many variables that go into selecting the correct code. The question many providers are left with is: who has time to reference the various guides and available resources when trying to complete a patient visit? Unfortunately, inaccurate coding can lead to significant penalties and lost revenue.

The Consequences of Medical Coding Errors

The good news is that changes are coming. Starting in 2021, time-based billing will be available for applicable services, dramatically reducing the complexity associated with code selection. CMS alone has reported a 9.2% monetary loss due to incorrect coding and 55.2% loss due to insufficient documentation in the CY of 2019. If you were to submit an incorrect claim to the government, this would violate the Federal Civil False Claims Act (FCA). Penalties may include substantial fines and even possible imprisonment. As frightening as those repercussions are, the most common consequence of medical coding errors is not receiving reimbursement from the insurance carriers. 

It’s about time we actually apply the infamous motto “patients over paperwork” and remove the providers’ burden of having to recite coding guidelines. Thus, eliminating the fear of possible sanctions due to inaccurate coding.

pMD Helps Solve Coding Problems & Meet Medical Billing Needs

At pMD, we can create customized edits designed to prompt providers to select accurate codes based on specific parameters and requirements, such as charge code or diagnosis criteria, NCCI edits, patient demographics, and much more. This is a quick, seamless process that enables the provider and biller to feel confident in their code selection. Just a few extra clicks based on prompts can assist with accurate and timely claims submission. Additionally, it can result in quicker payment turnaround as well as the appropriate utilization of E&M codes. 

pMD is continuously evolving to serve the medical billing needs of practices. Contact us to learn more about how pMD can best assist you and your practice!

Related Articles:
Standardized Code Sets, Their Impact on Providers & the Solutions
Investing in Partnerships Pays Dividends
Electronic Health Records Don’t Reduce Administrative Costs - Mobile Charge Capture Does!

 

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



It seems you’ve made your way to pMD's blog and want to know more about what charge capture really is. This blog is your guide. You've heard the buzzword all over health care, so let's begin by answering the question, “What is charge capture?”

SO WHAT EXACTLY IS CHARGE CAPTURE?

Charge capture is a process used by doctors and other health care providers to get paid for their services. In its simplest form, charge capture is the process whereby doctors record information on their services, which is then sent out to different payers and insurance companies for reimbursement. For example, let’s say a doctor sees you in the hospital, and after 30 minutes of care, the doctor diagnoses you with hypertension. Both the hypertension diagnosis and the 30 minutes of care translate into separate codes which are eventually submitted for reimbursement.

HOW ARE CHARGES CAPTURED?

One of the big variables in charge capture among medical practices is the way in which doctors record and transfer this information back to their offices and billing staff.

Pop Quiz: What are doctors using to capture their charges?

A) Smartphones
B) Post-it notes
C) Spreadsheets
D) Cafeteria napkins
E) All of the above

The correct answer? E. There are numerous ways to capture charges, and as you may have guessed, some methods are certainly more effective than others.

WHY USE MOBILE CHARGE CAPTURE?

As an alternative to paper-based systems like index cards, hospital print-outs, or cafeteria napkins, electronic charge capture ensures faster reporting and greater billing accuracy. When doctors submit charges electronically, it also reduces data entry errors along the way and eliminates the need to decipher enigmatic handwriting. And when you’re busy caring for patients, who really has time to memorize thousands of diagnosis and charge codes? Plus, paper can't keep up with ever-changing government regulations such as MIPS, but electronic charge capture can incorporate many solutions right into the software to make things as easy as possible.

The best and most efficient form of charge capture involves using mobile devices, such as smartphones or tablets. Doctors can record their charges using a charge capture application on their phones, allowing them to enter charges on the go. With advanced code search functionality, it’s unbelievably fast and easy, giving providers a convenient way to select customized diagnosis codes during the charge capture process. And because they can submit these electronically, doctors no longer have to shuttle paper charges back and forth from the hospital to their office. In essence, it extends the practice to the hospital and the hospital back to the practice, so providers can stay on top of everything in real-time.

WHAT ABOUT SECURITY?

Mobile charge capture is also the most secure method because all of the data is encrypted, both on the device and in transit. This way, doctors don’t have to worry about misplacing a paper charge and putting confidential patient information at risk.

CHARGES ARE SUBMITTED, WHAT’S NEXT?

Capturing charges is one thing, but what comes next? Don’t worry, we’ve got you covered here as well! The next step is billing and collections, or to put it simply, getting paid. Another big benefit of capturing charges in pMD, is the ability to then bill for those charges without needing to use another software vendor and/or service. pMD streamlines the entire practice from point-of-care through reimbursement. With customizable prompts and easy, accurate code selection on the front-end, combined with claim scrubbing, transparency and reporting on the back-end; providers can take care of their patients, while our team of revenue cycle experts will take care of the medical billing and collections. It can be that easy! 

pMD provides intuitive, elegant mobile charge capture software that improves patient care and makes doctors happy. Learn more about pMD charge capture.

 

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