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.
To adjust to the ‘new normal’, here are some of the latest best practices for medical offices to implement.
In the current state of the world, filled with struggles brought on by COVID-19, many providers and practices are attempting to weave new procedures and workflows into their daily activities—to adjust to the ‘new normal’. This includes implementing virtual visits, exploring automation and paperless options, streamlining eligibility verifications, and strategizing on denials management.
An EZClaim partner, TriZetto Provider Solutions, has provided information about the latest best practices for medical offices. Their in-house experts offer some creative ways of how your practice can become more efficient and navigate through the pandemic with the following articles:
EZClaim’s medical billing software can ensure that you are equipped with the right solutions to manage costs and maximize revenue flow. Want to learn more? Well, visit their website, e-mail them at email@example.com, or call a representative today at 877.650.0904.
Reserve your place for a webinar that will inform you on how to increase your revenue with a proper medical billing verification strategy.
With increased patient financial responsibility, it’s extremely important to proactively check your patients’ benefits coverage and provide payment estimates to avoid any unexpected costs. By enhancing your medical billing verification strategy and providing patient financial transparency upfront, it increases the likelihood that you’ll rake in more revenuethis season.
Join EZClaim and TriZetto Provider Solutions, a Cognizant Company, for a webinar on Thursday, October 29, 2020 at 1 p.m. ET, to discover strategies your practice can catch falling revenue through seamless integration and automation.
During This Webinar We Will Discuss:
• Patient Responsibility Estimation: Quickly obtain patient financial estimates at the point of service to help increase patient revenue, decrease billing costs, and improve patient satisfaction through price transparency.
• Integrated Eligibility: Connect to payers through a single application to get the most up-to-date information on patient coverage, co-pays, deductibles, and more. Proactively verify patient eligibility, for up to 50 patients at a time directly from your EZClaim Premier program.
• Insurance Eligibility Discovery: Submit a real-time eligibility request using minimal data and identify a patient’s insurance carrier in a matter of seconds. Maintain groups of your common payers and easily locate active patients and full eligibility benefits on our website.
EZCLAIM: EZClaim is a medical billing and scheduling software company that provides best-in-class customer service and support. To learn more, e-mail them at firstname.lastname@example.org or call a representative today at 877.650.0904.
TRIZETTO: TriZetto combines innovative, proven products with an exacting commitment to serving our customers, in order to provide you with the tools you need to effectively manage your reimbursement cycle.
A group of senators introduced the “Health Care PRICE Transparency Act”in a move to empower patients to lower their healthcare costs.
On a basic level, the Act will require all medical facilities to post payer-negotiated rates for all shoppable services, so the patient can find the most inexpensive way to take care of their medical needs. This legislation will give Americans the chance to see the actual costs of their healthcare visits, which in theory, will increase competition and lower healthcare costs for everyone.
The added transparency of the Act will bring more accountability and competition to the healthcare industry, and gives American’s more control over their healthcare costs. However, if you are a medical practice, a hospital, or a member of the medical billing community, you need to know how you can best respond.
• “What is this procedure going to cost?”: There is going to be mounting pressure on practitioners, medical billers, and hospitals to have answers for the cost of procedures. Jeff Leibach, a director with Guidehouse’s healthcare strategic solutions team, says that “regardless of the legal fate of the final rule, hospitals need to be prepared for more price transparency in the future.” So, to get in front of this—and help you compete against your competitors—you should be prepared with both what it will cost for individual services and procedures, as well as, a ‘value statement’ on why it will cost what you are charging.
• Prepare to Comply or Cover the Costs: As it stands now, the legislation is moving towards technology assisting with the billing transparency. This will aid the patients to better understand the cost of services. This is a ‘clarion call’ for you to begin preparing for this reality or you will struggle with being fined and potentially publicly shamed in publications for being offenders. We recommend starting to comply NOW before the deadline ‘sneaks up’ on you.
• Use It To Improve: Currently, healthcare practices are, in many cases, already working at capacity. The added effort of defining cost and selling procedures are enough to make some healthcare facilities put this off until it is too late. Yet, while many may be considering accepting the fines and fees associated with non-compliance, we advise using this as an opportunity to improve—to better establish your medical practice’s services, and promote your ability to be proactive to change. Getting ahead of the coming ‘wave’ of consumer expectations of healthcare will be a benefit.
• Seek Out Vendors That Can Assist: The changes that are coming for individual practices and healthcare providers can be overwhelming, and potentially it might just be more than what an IT team or private practice can handle. Forward-thinking billing departments should be investing in software vendors that can help fill that gap. EZClaim is a medical billing software company that partners with Trizetto to provide a tool called, Patient Responsibility Estimation(PRE). This tool assists in clarifying costs to consumers by providing a cheap and fast way for them to pay for out-of-pocket costs. [ Click here to learn more about how EZClaim can help you ].
It is clear that the expectations of consumers are changing, and the wave of medical transparency is on its way. Accepting it, preparing for it, and using vendor software to help overcome it, can be the difference of your practice avoiding fines and fees. For those forward-thinking and proactive practices who want to learn about how EZClaim can help, e-mail one of their sales representatives, go to their website for more details, or download a FREE 30-day trial today!
If you are a member of the MEDICAL BILLING COMMUNITY, the norms of the day-to-day have changed. With the recent COVID-19 pandemic and the ‘stay-at-home’ order, you may find yourself with either more time on your hands and/or an increase of claims with new patients. During this time, we want to offer you a couple of suggestions so that you can make the best use of the additional time you have, and also help you improve your billing processes.
The first thing to consider is to review your Accounts Receivable (AR)—to collect payments due you to INCREASE YOUR INCOME. According to the American Medical Association (AMA), claim denial rates range between 0.5% and up to 3% or more, and that 90% of claim denials are preventable. Some of the most common claim denial reasons can be rectified by correcting claim management workflows, including claim submission and patient registration procedures. The following are a few of the most common oversights for claim denial.
Use EZClaim software to check automatically for missing information, including absent or incorrect patient demographic information and technical errors
Make sure you do not have duplicate claim submissions
Check that claims do not have services previously adjudicated
Review for claims with services not covered by the payer
Make sure the time limit for claim submission has not expired
Secondly, revisit and resubmit open claims. Surprisingly, 31% of providers still use a manual process to resubmit. Our partner,TriZetto Provider Solutions (TPS), has anAdvanced Reimbursement Manager Pro (ARM) that has two great tools that can improve your ability to tackle collecting and repaying underpaid and overpaid accounts. Below are some key features that can be automated by their software, and will help to improve your billing processes:
Identify common errors and payer trends
Analyze contract performance
Customize and assign work into queues
Quickly access information from interactive dashboards
Automate the appeal process
Thirdly, know thatEZClaim and our partnerTPS have worked together to bring you the most powerful medical billing software tools to solve claim denials. Our partnership not only simplifies the billing process but also helps resolve denied claims in an efficient way. In addition to that, ourcustomer support team is available to help you learn best practices with these tools, and support you however you need it.
Finally, if you are frustrated with your current medical billing solution, investigate how EZclaim’s medical billing solution may work for you. You can eitherschedule a one-on-one consultationwith our sales team ordownload a FREE TRIALto check it out the software yourself. For additional information right now, contact EZclaim’s sales team at877.650.0904or send an e-mail email@example.com.
On January 13th we posted part one in this topic of Eligibility in healthcare, in that, we touched on deductibles, co-pay, and max out-of-pocket pay. Now in part two, we review the impact of price transparency in healthcare and its importance to the healthcare team decisions.
Consumers are the most important member of the healthcare team and are better collaborators in their care when they know all the variables and their required responsibilities in the process.
The individual consumer’s healthcare team includes, along with themselves, the physician and their staff, the pharmacist, an insurance adviser and possibly some gatekeepers as well. The communication of clear symptoms when a patient is diagnosed is the responsibility of that team along with building an understanding of the financial responsibility that goes with any medical solution. While providing answers, options and solutions is a provider responsibility, so is providing a cost for the provided care. Therefore, price transparency can be achieved when the cost for that care is presented in a clear and concise fashion so the patient can understand what they owe, why they owe it and when it is due.
Ensuring your staff is educated on discussing the financial responsibility with the patient from the first appointment and forward will strengthen the healthcare partnership and assist in the collection process. Understanding the steps that occur post the upfront estimate can be beneficial to the team. This discussion can be bolstered by ensuring bills are clearly marked with the statement, “this is a bill”, also clearly listing what the patient is being charged for when the bill is due and offering details on the methods of payment that are accepted. This clarifies what insurance will cover for the patient and their own out-of-pocket cost, prompting them to share any concerns and constraints with payments upfront.
Estimating patient responsibility is one part of the reimbursement process that is used for transparency for patient billing. The estimates can be provided using a spreadsheet of prior reimbursement and your most commonly billed CPT codes. If you would like an automated and more accurate option then look into a software tool like the Patient Responsibility Estimator by our solutions partner, TriZetto Provider Solutions (TPS). Giving this to the patient at the time of checking in will assure they have a rough idea of the costs and allow the office to collect upfront if needed.
For more information on how EZClaim can help you with this journey, schedule time with our sales team. Ready to get started? Download your free 30-day Trial today!
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