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POSTS BY TAG | revenue cycle management

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.
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.
Increasing medical practice revenue


Medical practices can measure success in many different ways. When it comes to revenue, an upward trend is definitely a positive thing. There are actions a practice can take to ensure they don't see their revenue plummeting towards the point of no return. Here are 3 proactive approaches to increasing your medical practice revenue.

Provider Credentialing:


Medical credentialing is a crucial process in relation to the claim life cycle, but why? Credentialing is the first step in establishing a contract with the payer. By enrolling as an in-network provider, you can now leverage your agreements with the payer to ensure that you are reimbursed for your services and at the proper contractual rate. Without it, your practice risks losing thousands to hundreds of thousands of dollars in revenue per year as a result of denied claims or delays in adjudication. If you neglect your credentialing or make the slightest mistake on your application, you chance your enrollment being rejected and the consequences will be as severe as non-payment for your services.

Credentialing also opens up more opportunities for providers to expand their patient base. When credentialing with a payer, you’ll enroll with their networks, increasing the number of patients that now can be seen by your practice as “in-network.” This can have a direct impact on the number of referrals that you receive, which ultimately increases your revenue stream. Patients are more inclined to be treated by an in-network provider since it’s more cost-effective with less out-of-pocket expenses for the patient. The comfort of knowing that this provider has been vetted by the payer is also a factor that a patient takes into consideration when selecting a physician. 

You can begin by evaluating your local payers to determine which are worth pursuing contracts with. Although carriers will not disclose their fee schedule upfront, you can determine if that relationship will be beneficial based on the demand of your patient base. You have better odds of reimbursement as a participating provider. This will also put your practice at an advantage, allowing you to stay competitive across multiple avenues. You’ll find that if you’re growing your practice, physicians will be more likely to join a group with a larger network because of the benefits of credentialing. 

Physician Fee Schedule Negotiation: 


The next step is to evaluate the contractual rates assigned at the time of your enrollment. Many physicians do not bother to negotiate their rates as it can be another intensive process or they were simply unaware that this was a possibility. Great news - this is in fact an option and a great way to boost revenue for your practice!

When assessing your practice's financial health, it should be quite apparent where your revenue is generated from. Your financial reporting should identify your top paying carriers as well as your top-billed procedure codes. In pursuing higher reimbursement rates, you’ll want to begin by reviewing what the customary rate is for your region. You’ll then need to demonstrate the value that your practice can bring to the insurance network. One of the biggest factors to highlight is the cost savings you’ll provide due to your clinical outcomes. Another beneficial attribute is location and specialty. Is there a shortage of your specialty in the area? Will you continue to grow your practice consistently to offer a larger network for their patient base? 

Eligibility Verification:


Now that you have secured your contracts with payers and negotiated those contractual rates, your reimbursement will ultimately depend on the success of your eligibility verification process.

Unfortunately, many practices have experienced a scenario where the patient presented their insurance card, the billing department has submitted the charge to the carrier, and you later learn that the claim has been denied due to “subscriber not found” or “provider out-of-network.” Where do you go from here? Did your front office have the patient sign a waiver, such as an Advance Beneficiary Notice to allow you to legally bill the patient? Do you attempt to bill the patient and still run the chance of not getting reimbursed as the patient is unable to afford the balance? These are the challenges and tough decisions providers face when not validating the patient's insurance prior to the visit.

Luckily, these scenarios can be prevented by verifying the patient's coverage ahead of the appointment. Implement a streamlined process that will allow you to check eligibility electronically. If you decide not to use an electronic eligibility solution, the alternative will require your staff to spend countless hours calling various payers and will likely result in missed eligibility checks, inaccurate responses, or limitations to the data that can be provided. Not to mention, some serious overhead costs.

By integrating with an electronic solution, you can identify the specific health plan the patient is enrolled in and therefore determine provider participation status. You’ll also identify the patient’s out-of-pocket expenses, such as the remaining deductible prior to treatment. This enables you to leverage these responses to collect the patient's copay or deductible at the time of the appointment and in doing so, eliminate lag time in patient collections as well as prevent those dreadful denials. 

Running eligibility prior to a visit is a critical piece to ensuring your practice will be reimbursed for the services you’ve rendered. You’ve dedicated your time and hard work conducting your visits, let’s not let coordination of benefits stand in the way of you getting paid. Getting the eligibility responses is one thing, interpreting those responses is another. It’s possible that the insurance coverage will return as active but the patient’s primary plan is covered through what is considered an “Advantage Plan” and you may not participate in that network. 

Expertise & Services to Help Increase Medical Practice Revenue:


In all three scenarios, enlisting experts to help guide you through the credentialing, fee schedule negotiation, and eligibility processes as well as help identify key factors and trends is essential to seeing your revenue maximized. Here at pMD, our expert team provides you with the services and experience you need so you don’t have to navigate all this on your own. We offer free consultations and would be happy to evaluate your financial analytics to help maximize revenue for your practice!

Related Articles:

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.
Patient experience and revenue cycle management


Successful revenue cycle management, or RCM, can mean a lot of different things: financial stability, increased revenue, and reportable data. From submitting claims to collecting payments to reporting, practices rely on this process and its resulting data to help them identify trends and make important business decisions. But there is one essential factor to the success of RCM that is often overlooked and that’s the patient experience. We don’t inherently lump patient experience with financial upside, so why is it so important to RCM?

The patient experience cycle


When we think about the patient experience, we often limit its range to the visit itself or the care received. But what we don’t realize is that, more or less, there are multiple points of interaction outside of just the face-to-face encounter with a provider. From the time an appointment is scheduled to when the patient pays their bills, the quality of the patient experience depends on how smooth the process is at every point of the cycle. 

The patient payment process can be a particularly challenging one to navigate for many reasons. In some instances, patients are faced with paper statements that may arrive late in the mail or are possibly overlooked. Then, the patient would still be required to call the doctor’s office to make the actual payment via credit card or worse, would have to mail a check. Now imagine being able to receive statements via text or email and having the option to pay directly from there, or even at the point of service. Patients aren’t concerned with whether or not the practice is using an in-house versus outsourced biller nor do they really have visibility into such things on the backend. So, when it comes time for a patient to pay their medical bills, if the front end process is disorganized, unclear, or difficult in any way, you can bet the patient's experience suffers and the onus of that bad experience often falls squarely onto the practice, undoing all the hard work and thought put into providing great medical care.

Keeping the patient experience top-of-mind


Every step of the patient cycle plays a key role in providing a positive patient experience - appointment reminders, patient intake, gathering financial and insurance information, the encounter with the provider, the payment process - all of these combined make a strong case for a good experience, should everything go smoothly. Things like no-shows due to a lack of appointment reminders or sending paper statements that cause delays in timely payments can hinder not only a good patient experience but also the chances of collecting payments in a timely manner, if at all.

As a practice, it’s easier to provide that seamless experience when everything you need is in one place. At pMD, we care about what you care about. We’re a team that’s invested in the things you’re invested in. So naturally, your patients are our top priority. Our revenue cycle management service allows you to provide that top-notch patient experience while also seeing your revenue increase. Let us take care of the administrative work so you can focus on what matters most.

Related Articles:

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.
Ensuring a clean claim to avoid denial


If you were to Google, “What is RCM?” you’re not going to find an easy answer. At its most basic level, Revenue Cycle Management is defined as the financial process that health care practices and providers use to track patient care episodes. However, the search will spit out a myriad of definitions, and a laundry list of vendors, advertisements for new medical billing software, and companies promising to help improve your revenue cycle. Let us break it down for you. 

When does the revenue cycle begin?


Many vendors may say the revenue cycle begins when a provider renders a service to a patient. At pMD, we think of it a little bit differently. We believe the revenue cycle begins long before the patient even steps foot in the office or onto a video call. A successful revenue cycle starts at the point of patient registration and appointment scheduling. Making sure a patient is set up, ready to go, has paid their co-pay, and insurance has been verified prior to their appointment is crucial to ensuring the patient has a successful visit, and the provider is reimbursed in a timely fashion. In fact, one of the most common reasons for claim denials is due to “missing information,” such as the patient’s insurance or demographic information is not accurate, up to date, or incomplete. Finding a solution that helps you gather and verify correct patient information upfront, prior to an appointment, pays huge dividends in a practice’s eventual collections and overhead costs.

When does the revenue cycle end?


Some may argue that the revenue cycle ends when reimbursement from a patient and/or payer hits your bank account. Others might say that the revenue cycle never really ends, since the lifecycle of a patient relationship can be long and complex, with one episode of care bleeding into the next. Here at pMD, we believe that it’s all about consistently finding ways to simplify and shorten this cycle. Additionally, carrier relationships can be complex and iterative, meaning there is always room for improvement. One piece is clear though - the ultimate goal of an RCM partnership is to reduce the amount of time it takes for a practice or provider to get reimbursed for services, while also maximizing those reimbursements. As the saying goes, your dollar today is worth more than your dollar tomorrow. 

How do you measure the health of your revenue cycle? 


There are various metrics used to measure the efficiency of one’s revenue cycle, and the importance of each is going to depend on the individual practice and their unique priorities. The most commonly used measurement technique is known as days in AR, or accounts receivable. Days in AR is a measurement of the average time it takes to collect payments owed to the practice. Days in AR gives you a snapshot idea of how quickly you are getting reimbursed for your services, and by extension, how effective your revenue cycle is. Another common way to measure one’s revenue cycle is through overall collections, which can be drilled down further, to examine collection trends by payer or even by charge code. The appropriate metric used may depend on an individual organization’s specific needs or goals. 

What can I do to improve my revenue cycle?


Ask an expert! Here at pMD, our mission is to streamline and optimize as many areas of the patient care episode and the revenue cycle as possible. Through our integrated RCM software and services, we’re able to help practices consolidate vendors, reduce costs, streamline workflows, improve patient care and satisfaction, and collect your maximum reimbursement quicker. Not sure what a vendor could do to improve your financial metrics? Contact pMD for a no-commitment financial impact analysis by our team of RCM experts FREE of charge! 

If you are interested in learning more about pMD’s Billing & Revenue Cycle Management Services, please contact us here or give us a call at 800-587-4989 x2. 

 

Related Articles:

What are Comparative Billing Reports? 
Reduce Claim Denials with Real-Time Eligibility 
Is your revenue cycle vendor a true strategic partner?


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.
Overview of Comparative Billing Reports

 

In 2010 the Centers for Medicare and Medicaid Services (CMS) began to release Comparative Billing Reports (CBRs). A CBR compares provider to provider billing practices, both regionally and nationally, to determine if a provider is an “outlier”, or billing outside of the expected pattern. If a provider is found to be an outlier, they will receive a notification detailing the analysis and erroneous billing, while offering education on the topic. CBRs review many areas of billing, and even topics outside of billing. Some common topics include; evaluation and management, modifier utilization, and groups of specific codes, for example, radiation modality treatments for oncology providers or dialysis visits for nephrology providers. It's also important to note that CMS is not the only one reviewing billing practices in this manner. Other large commercial payers have similar programs, such as UnitedHealthcare’s Peer Comparison Reports, which functions much like the CBR.

What is a CBR used for?


CMS and other payers perform CBRs and similar reports with the goal of providing educational resources and outreach. This outreach ensures compliance with coding and billing standards and reduces potential fraud, waste, and abuse. CBRs can also ultimately help patients. Most patients are unaware of the many coding and billing rules that exist and therefore have a difficult time identifying when they have been overcharged. This can lead to costly out-of-pocket expenses toward co-insurance and deductibles. Educating providers can offer a real impact on reducing a patient’s financial burden.

What should I do if I received a CBR?


While CMS says “receiving a CBR is not an indication of or precursor to an audit” the receipt of a CBR can still be a stressor, especially if a provider or practice does not have the right tools to internally investigate the CBR findings, or worse, does not know where to begin to address a CBR. The risk of removing focus from the patient care to address these billing practices is high. Additionally, ignoring the report altogether could place the provider and practice at risk for more CBRs in the future and even potential audits. CBRs should be promptly reviewed and addressed by taking the following steps:

* Examine the issue identified in the report closely
* Evaluate the organizations or individuals billing patterns as they relate  to the CBR subject
* Perform a root cause analysis and address or correct any errors with education
* Continue to monitor the situation closely

How do I avoid a CBR?


One of the best defenses for CBRs and other billing challenges is to practice proactive risk analysis, or regular and consistent monitoring to identify potential billing issues before they begin. Proactive risk analysis can easily be achieved by utilizing the data that already exists within your billing software. Reports that visually display information such as charge capture counts or evaluation and management level distribution can be particularly useful. The same reports can then be combined with CMS benchmarking data, allowing a provider or practice to easily identify any variance from expected billing patterns.

These reports should paint a clear and visible picture, providing valuable insight. In the event a CBR is received the reporting can be used as part of the examination and subsequent monitoring following education on the error. Reports can also be supplied to coding/auditing or Clinical Documentation Improvement Departments as a resource to begin analysis for targeted internal education.

Taking a proactive approach to billing patterns can effectively decrease billing errors, support operational excellence and allow providers to spend more time focusing on patient care, which is the heart of pMD’s mission.

If you are interested in learning more about pMD’s Billing & 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.

 
Vendors that are strategic partners

 

In any given year, the changing healthcare landscape presents an ever-moving target. To keep up, busy practices may add a new vendor to address each problem they encounter. Further, on average teams with a clear goal may end up managing 3-8 vendors to execute that initiative fully. The result?  Teams became numb to the slow shift from managing priority problems to managing a growing list of vendors. 

Then 2020 happened. The disruption to clinic operation opened the eyes of many clinic operators and provided a unique moment of clarity. Looking at a laundry list of vendors to pay, teams were asking themselves difficult questions — how many of these relationships are essential? Which of these vendors are actually looking out for my business?


Teams turned the year poised to take more control in 2021. Seeking to reduce the risk that was exposed, clinic leadership has been actively consolidating the number of vendors they now manage. A recent technology industry survey reported more teams, nearly 10% greater than two years earlier, claim to now use up to 20 vendors. Further, fewer teams believe that it is easy to manage multi-vendor environments, down from 26% to 17%, while the number of those who see managing such an environment as “very challenging” has gone up by 8%. 

The benefits are clear and so the decision to reduce the number of vendors may be an easy one on paper. But the act of consolidating, and thus removing some vendors who may be performing a small task well, forces teams to look critically at the vendors they use today and to identify true strategic partners with which they will align for the future. 


Identifying Real Partners & Opportunities to Consolidate Vendors


A good first step to this process is to create and keep a vendor “score," routinely reviewing a vendor’s performance, grading them on key aspects of your relationship. Another good option is to review all your contract terms and establish a calendar reminder set for before that contract renews. Use those established timelines to investigate options to consolidate a current contract into a vendor who’s already performing well in another area and who may now offer a similar feature/service. As vendors expand their features and services to provide overlapping solutions, the opportunity to strategically consolidate vendors may be easier than you think.

But be mindful of the vendor’s ability to influence this trend. Some smaller clinical teams have shared that they may be facing fees upwards of tens of thousands of dollars to end an existing contract. Larger teams may face multi-million-dollar fees to end a relationship. These high fees can lead to inaction on the part of the clinical team and a lack of engagement with that vendor that has the compounded impact of complacency on the part of the vendor where the “chosen” vendor begins to lose their competitive edge. 

The Partner with Integrated Revenue Cycle Software & Services


When considering reducing the number of vendors you are managing, remember that the right partner should feel like an extension of your team. And any teammate needs to have time invested to fully realize all the benefits from that relationship. An integrated revenue cycle software and services partner like pMD pairs our team of national RCM experts and industry-leading software engineers to deliver control and ownership over revenue cycle metrics to prepare you for whatever the future may bring.

If you are interested in learning more about pMD’s Billing & 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.

Related Articles:

When to Consider Breaking Up with Your Medical Billing Company
Investing in Partnerships Pays Dividends
Interfacing Health Care IT Systems - Accuracy and Efficiency Should Not Cost Extra
Patient making payment using smartphone


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. 

Patients Want a Better Healthcare Payment Experience


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. 

Real Time Eligibility & Patient Responsibility Estimate Tools Help


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. 

Make Paying Medical Bills Fast & Easy for Patients


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.

Find Out How pMD Medical Billing & RCM Services Can Help


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.

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* Reduce Claim Denials with Real-Time Eligibility


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.

Learn About pMD Medical Billing & RCM Tools & Services


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.

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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.