Medicare is the largest payer for most practitioners, so it’s important that providers maintain current credentials. Medicare requires providers to revalidate every five years to verify credentials and ensure they meet Medicare qualifications. Providers must confirm or update information including the legal entity name, physical address, phone, fax, national provider identifiers, employer identification number, and board certifications and licenses if applicable.
While typically a straightforward process, if not completed correctly and on time, providers will be terminated from the program and required to reapply. Until a new application is processed and approved, which can take anywhere from 90-120 days, reimbursements will stop, disrupting the revenue cycle.
Occasionally, providers may receive off-cycle revalidation requests. These are typically triggered when anomalies are identified such as billing rates that are significantly higher than other providers in the same geography, billing for services not rendered, or billing patients for services that Medicare doesn’t allow.
To comply with Medicare revalidation requirements, providers need to know their revalidation schedule and make sure applications and supporting documentation are submitted through Medicare’s PECOS online application portal. Revalidation dates cannot be extended, so it’s important they’re submitted on time. Using a third party to navigate the nuances of Medicare revalidation and PECOS removes the burden from provider staff and ensures accurate and timely filing.
Having nearly four decades of experience working with payers and providers, the TPS credentialing experts understand the importance of maintaining current credentials. Contact us to learn more about our Medicare revalidation services.
ABOUT EZCLAIM: As a medical billing expert, EZClaim can help the medical practice improve its revenues since it is a medical billing and scheduling software company. EZClaim provides a best-in-class product, with correspondingly exceptional service and support. Combined, EZClaim helps improve medical billing revenues. To learn more, visit EZClaim’s website, email them, or call them today at 877.650.0904.
It’s safe to say that healthcare practitioners are well aware of the importance of credentialing. Beyond the legalities required of practicing physicians, credentials are needed for a practice’s revenue cycle to function properly. If providers aren’t enrolled with payers, they can’t receive payment for submitted claims. It’s as simple as that.
New and existing providers are required to maintain credentials and it’s not an easy process, even for the most well-oiled office. In order to take on the most patients and collect optimal revenue, practices also need to accept a wide array of payers. In fact, there has been a 5 percent uptick in providers enrolled with 10-20 payers, according to VerityStream’s 2018 Provider Enrollment Survey. Gaining enrollment with these payers involves verifying qualifications in order to accept patients, submit claims and ensure a steady stream of cash. Administrators need to collect the educational history of providers, fill out forms and submit the applications. It sounds easy enough, right?
Think again. There are hours of administrative work needed and a high risk for human error, with any hiccup in the process likely causing delays. It’s been said that up to 85% of credentialing applications are incomplete, which could cause delayed billing, lost revenue or even audits.
When it comes to credentialing, time is money. A 2016 survey by Merritt Hawkins found that a non-credentialed doctor was losing approximately $6,600 a day. Multiply that by the total amount of physicians in a given practice, and the potential losses are staggering.
Credentialing is a necessary evil, so do you handle in house or outsource? That’s the million dollar question. Utilizing current staff resources sounds like the easy solution, but does your organization have a dedicated employee to focus on your credentialing needs? Probably not. Chances are, this employee is pulled in many directions and isn’t able to dedicate time solely to credentialing. And if you do plan to handle the process with current staff, are your employees well-versed in all payers and their processes? Factor in learning curves or potential staff turnover and the time associated with training new employees and the not-so obvious financial costs quickly add up.
So how does the average practice streamline the process and ensure that credentials are gained as painlessly as possible? The old adage “you get what you pay for” could easily apply to this scenario. Hiring an outside resource means you are essentially paying for expertise and efficiency, which will save time and money in the long run. Why wouldn’t you want to utilize expert resources with in-depth knowledge of payer and state nuances? However, before making a decision, you need to know how much your practice could save by using a third party. Knowledge is power and having an accurate picture of your potential revenue is the first step to determining the best option for your organization.
Access the credentialing ROI calculator from TriZetto Provider Solutions, a Cognizant Company, to receive an estimate of potential revenue savings. Discover the hidden costs associated with the credentialing process and see just how much revenue your practice could gain in 2021. You’ll gain enrollments quickly and accurately, keep employee satisfaction levels high (since they won’t be burdened by the process) and ultimately, increase revenue.
Don’t allow the complicated payer credentialing and enrollment process to be a burden on your practice. The credentialing experts at TriZetto Provider Solutions have experience working with various payers and providers of all backgrounds. Our team will collect and submit information in a timely manner and perform all necessary follow-up tasks. Let us lighten your load so you can focus on patient care and growing your practice.
[Contribution by TriZetto Provider Solutions Editorial Team]
In the world of healthcare revenue cycle management, there are numerous scenarios that can put a stranglehold on your revenue if you’re not prepared. With the COVID-19 pandemic causing varying degrees of change in inpatient volumes and visits, and telemedicine coming further into play, physicians and their practices are having to quickly navigate the nuances of their financial well-being. A practice may be buttoned up from the time the patient walks in the door, but what happens after the visit will determine when the practice will get paid. This element of the revenue cycle starts with coding. Here are five medical coding challenges that will ruin your bottom line.
1. Coding to the Highest Specificity
Missing data on a claim relative to the patient’s diagnosis and procedure can easily cause a rise in denials once received by the payers, resulting in potentially thousands of dollars in write-offs. Medical coders are responsible for coding patients’ claims to the highest level of specificity, ensuring the appropriate CPT, ICD-10-CM, and HCPCS codes are applied based on the patient’s chart from the day’s services.
COVID-19 and telemedicine are frequently bringing on new codes and code sets, all with different variations and modifiers to make the matter even more complex. Medical coders spend a lot of time researching and learning new codes, but every year – and throughout the year – changes and updates are made. Payers don’t only want to know the diagnosis and the treatment; they want to know the cause as well. The Coronavirus Aid, Relief, and Economic Security Act passed in March of 2020 allows for an additional payment from Medicare of 20 percent for claim billed for inpatient COVID-19 patients, however, it was later indicated that a positive COVID-19 test must be stored in the patient’s medical records in order to be eligible for this payment. Being able to stay on top of codes specific to the patient’s diagnosis at treatment is more difficult than ever before.
While code specificity is important, so too is ensuring the claims do not contain codes for exaggerated procedures, or even procedures that were never performed, resulting in reimbursement for these false procedures. This seems logical enough, but upcoding can easily occur as a result of human error, misinterpretation of a physician’s notes, or lack of understanding of how to appropriately assign the thousands of ICD-10-CM codes in existence. To add to the pressure, the Office of the Inspector General issued a plan with objectives to prevent fraud and scams, and remedy misspending of COVID-19 response and recovery funds.
Much like under-coding or not providing enough data on the patient’s visit can create issues, upcoding can be a major contributor to financial loss for a practice. Questionable claims can be denied and sent back for corrections and appeals, but upcoding can have more serious ramifications outside of paper-pushing between coders and payers.
Whether it’s making sure the codes are in accordance with the care provided, understanding the code sets that apply for each procedure, or comprehension of the medical record, refraining from upcoding will help ensure a sturdy and compliant revenue stream.
3. Missing or Incorrect Information
There’s a common theme to coding challenges, and that’s having the sufficient information necessary. This information typically is pulled from a patient’s chart or record of a visit, which is often completed by the attending physician. However, even when a claim is submitted, providing required information relative to the procedure to the payer is critical as well. Situations such as failure to report time-based treatments (such as anesthesia, pain management, or hydration treatments) or reporting a code without proper documentation can result in denials.
Furthermore, information in a patient’s electronic health record may also contain inaccurate information. Keystrokes and other human errors can cause these situations to flare up, and it takes a diligent, thoughtful coder to read between the lines and ensure claims have the appropriate information.
4. Timeliness of Coding
The Medical Group Management Association (MGMA) suggested in their 2018 Setting Practice Standards report that a Primary Care Physician should maintain a claim submission rate of 3.11 days after the date of service, but it is becoming increasingly difficult for practices to sustain anything close to this rate. Constant changes to code sets, an increased focus on submitting claims with sufficient and compliant information, and the requirement to code claims to the highest level of specificity, can easily delay the submission by days or weeks.
Nevertheless, delays in coding and submitting claims can cause major lags in payment and substantial loss in revenue. Insurance payers have statutes of limitations that require claims to be submitted anywhere from 120 to just 60 days after the date of service. Simply put – the more time spent coding the claim, the later it will be submitted, thus increasing the odds that the claim will be denied. Expert coders are aware of this and do everything in their power to get coded claims out the door.
5. Staffing Shortages
However, finding experts well versed in coding claims quickly, accurately and in compliance with the False Claims Act is not always an easy task. As you can imagine, the increasing need for care within the senior population is causing a rise in claim volumes, and trying to find a team of coders who know the ins and outs of complex ICD-10-CM coding can easily cause a bottleneck in the revenue cycle. Health executives expressed their struggles to find talent back in 2015, and some forecasts expect a decline in commercial payments by 2024 to further hamper a C-suite’s ability to manage labor costs. The ramifications of incorrect coding are still a key topic of discussion to this day.
The time has come for practices to begin looking outside of their organization for coding support. How is your practice planning to tackle the coding conundrum? When choosing a partner for your medical coding needs, you need to pick an expert to help your practice stay on target. TriZetto Provider Solutions, a Cognizant Company, has available highly-trained, AAPC & AHIMA certified coders with the experience of getting the details right the first time and understand the importance of coding to the medical practice.
For more information about TriZetto Provider Solutions, a partner of EZClaim, visit their website, contact them, or give them a call at 800.969.3666.
ABOUT EZCLAIM: EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support. Combined, they help improve medical billing revenues. To learn more, visit EZClaim’s website, e-mail them, or call them today at 877.650.0904.
[ Contribution of the TriZetto Provider Solutions Editorial Team ]
It’s a story we hear too often. A person visits a hospital for a medical issue—whether it be a trip to the emergency room for a broken arm or a pre-scheduled appointment for a headache that just won’t go away—and receives a myriad of services and tests. Then comes the dreaded bill in the mail a few weeks later. Although they may inquire about an estimate at the time of service or have an idea of their coverage, the exact financial responsibility is often a mystery until that bill arrives. While the changes vary greatly, one thing that is certain: many people have trouble with their out-of-pocket costs. So much so that a recent survey from The Commonwealth Fund found that 72 million Americans have some sort of trouble with medical debt.
So, on January 1, 2021, the price transparency rule was put into effect—from the Centers for Medicare and Medicaid Services (CMS)—requiring all hospitals within the United States hospitals to publish the prices of various medical procedures. In particular, standard charges for services and items must be published online, available for patients to access. Until now, these prices were hard to find. The timing of this change—the beginning of the calendar year—comes at a time when healthcare pricing is top of mind since many customers most likely renewed or changed insurance carriers and coverage on January 1, 2021. With this comes a focus on out-of-pocket costs, deductibles, and more.
What Brought About This Radical Change?
Part of this change can be attributed to the consumers themselves. With the increase in high deductible health plans and increased out-of-pocket costs, finances are top of mind. In addition to these factors, today’s consumers demand a better overall patient experience. With the prevalence of online shopping, patients expect the same seamless transaction at the hospital that they receive with companies like Amazon, Walmart, and Home Depot. Just as consumers read product reviews before placing an item in their online shopping cart, patients research services and access peer reviews of physicians before they go to the office. In short, they want to be knowledgeable about their healthcare and crave tailored services with exceptional customer service.
Many believe this change will be well received, with Forbes calling the ruling a “gift to all Americans.” From the consumer’s standpoint, it will now be easier to make educated decisions based on cost. This will then cut down on the “unknown”—hopefully eliminating those hefty surprise bills—and opens the door to comparison shopping. Advocates are hoping this newfound transparency will eventually lower costs, with the competition eventually driving down the prices.
How Can Healthcare Organizations Navigate This Change?
This will not only promote transparency but will also increase convenience. By enabling patients to access and pay their bills on their own schedule with easy-to-implement solutions, organizations are meeting them halfway, so to speak. With easy-to-understand statements, integrated credit card processing, and 24/7 payment portals, it is no longer a hassle to manage medical financials. For healthcare organizations, facilitating proactive management of a person’s cost of care accelerates revenue collections and patient satisfaction improves.
In the larger sense, executives recognize that patients are taking more stock in their personal care. In order to thrive, hospitals and health systems must work toward creating the optimal patient experience, beyond just price transparency. With this, providers should aim to be more engaged and C-suite executives should try to provide additional benefits to their patients.
What Will This Mean for the Future of the Industry?
Only time will tell what the price transparency will mean for the industry. However, it is safe to say that this concept has the possibility to shape healthcare policies and processes for years to come.
So, for more information on solutions that equip you to have informed conversations about eligibility and financial responsibility, contact one of EZClaim’s partners, TriZetto Provider Solutions, to talk with one of their representatives today.
EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support. Combined, they help improve medical billing revenues. To learn more, visitEZClaim’s website,e-mail them, or call them today at 877.650.0904.
[ Article contributed by TriZetto Provider Solutions Editorial Team ]
The COVID-19 pandemic has put a spotlight on the need for mental health resources as illness, job losses, and isolation continues to create unprecedented stress levels. According to recent surveys conducted by the Larry A. Green Center, more than half of clinicians reported declining health among patients due to closed facilities and delayed care, and more than one-third noted that patients with chronic conditions were in noticeably worse health as a result. Even more striking, over 85 percent reported a decline in inpatient mental health with 31 percent seeing a rise in addiction.
With mental health access at the forefront of our minds, there is no doubt a demand for qualified professionals that can handle these complex patient needs. While the sense of urgency for these services exists, especially as more and more healthcare consumers are resuming in-person appointments, unfortunately, there are processes in place that can create unnecessary roadblocks for practitioners.
Complying with the Council for Affordable Quality Healthcare’s (CAQH) behavioral health credentialing requirements are especially challenging. Unlike traditional medicine, treatments and therapies for conditions such as addiction are not as well understood by payers. This makes it more difficult to gain or maintain the credentials necessary to submit claims for therapy services.
Ninety percent of the time counselors and therapists apply for network status are denied! That’s a striking statistic, even for seasoned professionals, and everyone can agree that appealing denials and requesting payers review credentials in greater depth are a time consuming and expensive burden. On average, the time required for behavioral health credentialing of professionals is up to five times greater than for medical professionals because of nuances specific to the industry. The turnaround for completed enrollments is slower too, on average 180 days versus 120 days. In addition, some payers will only allow certain therapies for providers without advanced degrees. Because denials for behavioral health are common, therapists must understand which therapies a network will accept and focus on therapy-specific credentialing. In the current environment, practitioners should also ensure that Telehealth or virtual appointments will be covered for the safety of all.
So how can mental health providers stay ahead of enrollments and avoid credentialing-related denials? Outside assistance from experts like those at TriZetto Provider Solutions offers an end-to-end credentialing service that ensures continuous payer follow up and insight into enrollment status. Our credentialing professionals are devoted to helping providers gain and maintain their credentials. We understand the nuances associated with behavioral health credentialing and have direct relationships with all major payers. TPS allows you to do what you do best – manage patient care – by alleviating the burden of credentialing and making sure you never miss quarterly re-attestation deadlines.
If your mental health services are being denied, we are here to help. Learn how solutions from TriZetto Provider Solutions can help your practice simplify credentialing.
After the examinations, x-rays, and surgeries, lives another major part of a physician’s day that happens behind the scenes. All the hard work needs to be processed through a successful claim submission, meaning that ultimately earning payment all boils down to one thing – coding. Evaluation and management codes, or E/M codes, are codes a physician uses to report a patient visit. This administrative task – a necessity for any physician – is often cumbersome and prone to errors. Most importantly, it uses up valuable time that could be better spent.
How many of us have experienced the “hurry up and wait” scenario? The type of appointment where you wait in a waiting room, then wait a little more in the exam room, then eventually get 10 minutes with your doctor…only to be rushed out so the next patient can be shuttled in. Unfortunately, it’s all too common. It’s safe to say that many patients could benefit from more face-to-face interaction with their providers.
Many people claim that payment for evaluation and management services is undervalued, specifically when it comes to ambulatory services. Additionally, it’s been argued that the fee schedule itself is not well-designed to support primary care, which requires ongoing care coordination for patients. Pressure existed to increase payment rates for ambulatory E/M services while reducing payment rates for other services. Thankfully, The Centers for Medicare and Medicaid Services (CMS) took notice. With the goal of increasing efficiencies to reduce unnecessary burdens, the “Patients over Paperwork” initiative was established. Per CMS, E/M codes make up 20% of total spending under the physician fee schedule. Part of this initiative aims to reduce the coding and documentation requirements for E/M codes, in turn giving physicians more time to spend with patients. In partnership with The American Medical Society (AMA), CMS worked to revise the rules for evaluation and management coding requirements. These changes were finalized in the 2020 Physician Fee Schedule (PFS) with an effective date of January 1, 2021.
So what exactly was revised? The E/M updates affect codes 99201 through 99215 and include the deletion of code 99201 along with revisions to the code selection for 99202 – 99215. Below is a summary of the revisions to E/M codes:
Elimination of code 99201
Decrease the burden of coding requirements
Decreases the burden of documentation
Decreases the need for audits
Revises the definitions for Medical Decision Making (MDM)
Revises the definition of time spent with the patient to total time including non-face-to-face for E/M services by a physician and other QHP
Requires a history and/or examination when medically< necessary
Offers a clear time ranges for each code for time spent with the patient
Addition of a new 15-minute prolonged service code
Clinicians will choose a code based on MDM or total time
These changes apply to office visits and other outpatient services. It’s noteworthy that these changes represent the first changes to the E/M codes in over 25 years! More importantly, the changes streamline the coding process, reduce clinician burden, and will allow physicians to put the focus back on patient care.
Billing and coding should always be top of mind, but it can be hard to keep up. This is why it’s critical for physicians, clinicians, coders, and billers to completely understand these changes. To help comprehension, the AMA released a checklist identifying ten steps to help the practices prepare for the upcoming changes that can be accessed here. To learn more about the medical coding changes and the summary of revisions, visit the AMA website.
Note: This article is not a comprehensive overview and is NOT intended to provide coding advice, rather it is intended to highlight the new changes in effect and the need for physicians to ensure they have received the proper training for the upcoming changes.
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