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.
Ransomware hackers target medical billing companies, and it CAN AFFECT your entire company! (Ransomware is a type of malicious software designed to block access to a computer system until a sum of money is paid.)
Often out of one’s control, ransomware hackers target medical billing companies because of the tremendous value of the data. BUT, there are steps that CAN BE TAKEN to protect you, your company, and your patients and/or clients.
NetWalker Ransomware, for example, gained notoriety for targeting hospitals and healthcare providers with e-mails claiming to provide information about COVID-19. (The e-mail usually has an attachment that downloads the ransomware from a remote server when clicked on.) The thing is, this is very lucrative for identity thieves since medical records information sells anywhere from $1-$1000!
As the number of healthcare providers taking advantage of Telehealth continues to increase—now outnumbering in-person visits—the number of ransomware attacks continues to increase as well. This means Billers and Providers must be aware of the programs that are used on their machines and ensure necessary steps are taken to safeguard against hackers and attacks.
How can you protect yourself and/or your organization?
Carefully monitoring where you store and enter your passwords can be extremely beneficial to help minimize the risk of a hack and keeping personal or patient information protected.
Routine password changes and monitoring where you store and enter your passwords can be extremely beneficial to help reduce the risk of becoming a victim to a hacker. Passwords should be long, unique in characters, capitalization, and alphanumerical.
Have you had an accurate and thorough Security Risk Assessment and/or penetration testing? If you haven’t completed an accurate and thorough security risk assessment, you could also be penalized under ‘willful neglect’ (this category alone is $50,000 per violation!) in addition to the higher risk of ransomware attacks.
If you believe you might have revealed sensitive information about your organization, report it to the appropriate people within the organization, including network administrators. They can be alert for any suspicious or unusual activity.
The strength of your passwords directly impacts your online security.
Live Compliance can help. They aggregate breaches which enables you to assess where personal data has been exposed. Dark Web scanning is built right into their Portal, and it allows you to keep an eye on employees whose information was involved in a breach, where the breach took place, and then suggest the next steps to take.
At Live Compliance, they make checking off your compliance requirements extremely simple and to ensure this doesn’t happen to you or your organization:
Reliable and effective compliance
Completely online, our role-based courses make training easy for remote or in-office employees
Contact-free, accurate Security Risk Assessments are conducted remotely. All devices are thoroughly analyzed regardless of location. (Conducting an accurate and thorough Security Risk Assessment is not only required but is a useful tool to expose potential vulnerabilities, including those such as password protection.)
Policies and procedures curated to fit your organization ensuring employees are updated on all workstation use and security safeguards in the office, or out of the office—all updated in real-time
Electronic, prepared document sending and signing to employees and business associates
So, don’t risk your company’s future on ransomware hackers. Contact one of EZClaim’s partners, Live Compliance, especially since they are offering a FREE Organization Assessment to help determine your company’s status. E-mailthem, visit their website at LiveCompliance.com, or call them at 980.999.1585.
For more information about EZClaim’s medical billing software, which provides a best-in-class product with correspondingly exceptional service and support, e-mail, visit their website, or contact them at 877.650.0904.
[ Article contributed by Jim Johnson of Live Compliance ]
There are five ‘phases’ in the life cycle of a medical bill: Pre-appointment; Point of care; Claim submission; Insurance payment or denial; and Patient payment. This post will overview each of these phases, and could even be considered to be a “101-level” course on Revenue Cycle Management.
The revenue cycle is the series of processes around healthcare payments—from the time a patient makes an appointment to the time a provider is paid—and everything in between. One way to think of it is in terms of the life cycle of a medical bill. Although there are many ways this process can play out, this post will lay out a common example below:
1. Pre-appointment For most general care, the first stage of the revenue cycle begins when a patient contacts a provider to set up their appointment. Generally this is when relevant patient information will begin to be collected for the eventual bill, referred to on the financial side of healthcare as a claim.
At this point a provider will determine whether the appointment and procedure will need prior authorization from an insurance company (referred to as the payer). Also, the electronic health record (EHR) used to help generate the claim is created, and will begin to accumulate further detail as the provider sends an eligibility inquiry to check into the patient’s insurance coverage.
2. Point of care The next step in the process begins when the patient arrives for their appointment. This could include when a patient arrives for an initial consultation, an outpatient procedure, or for a follow-up exam. This could also include a Telehealth appointment.
At any of these events, the provider may charge an up-front cost. One example of this is a co-pay, which is the set amount patients pay after their deductible (if they are insured), however, there are other kinds of payments that fall into this category, too.
3. Claim submission After the point of care, the provider completes and submits a claim with the appropriate codes to the payer. In order to accomplish that, billing staff must collect all necessary documentation and attach it to the claim. After submitting the claim to the payer, the provider’s team will monitor whether a claim has been been accepted, rejected, or denied.
[ Note: Medical coding refers to the clerical process of translating steps in the patient experience with reference numbers. The codes are normally based on medical documentation, such as a doctor’s notes or laboratory results. These explain to a payer how a patient was diagnosed and treated, and why. This information helps the payer decide how much of an encounter is covered under any given insurance plan, and therefore how much the payer will pay. ]
4. Insurance payment or denial Once the payer receives the claim, they ensure it contains complete information and agrees with provider and patient records. If there is an error, the claim will be rejected outright and the provider will have to submit a corrected claim.
The payer then begins the review process, referred to as adjudication. Payers evaluate claims for accurate coding and documentation, medical necessity, appropriate authorization, and more. Through this process, the payer decides their financial obligation. Any factor could cause the payer to deny the claim.
If the claim is approved, the payer submits payment to the provider with information explaining details of their decision. If the claim is denied, the provider will need to determine if the original needs to be corrected, or if it makes more sense to appeal the payer’s decision.
Following adjudication, the payer will send an explanation of benefits (EOB) to the patient. This EOB will provide a breakdown of how the patient’s coverage matched up to the charges attached to their care. It is not a billing statement, but it does show what the provider charged the payer, what portion insurance covers, and how much the patient is responsible for.
5. Patient payment The next phase occurs when the provider sends the patient a statement for their portion of financial responsibility. This stage occurs once the provider and payer have agreed on the details of the claim, what has been paid, and what is still owed.
The last step occurs when a patient pays the balance that they owe the provider for their care. Depending on the amount, the patient may be able pay it all at once, or they might need to work with the provider on a payment plan.
The above example represents one way the lie cycle of a medical bill can play out. Some of the ‘phases’ are often repeated. Because of the complexity of healthcare payments and the parties involved, there is not always a ‘straight line’ from patient care to complete payment. That’s why we call it the revenue cycle, and there are companies that provide systems for its management.
One of EZClaim’s partners, Waystar, aims to simplify and unify healthcare payments. Their technology automates many parts of the billing process laid out above, so it takes less time and energy for providers and their teams, and is more transparent for patients (Click here to learn more about how Waystar automates manual tasks and streamlines workflows.) When the revenue cycle is operating at its most efficient, providers can focus their resources on improving patient care—and that’s a better way forward for everyone!
For more information of how Waystar works together with EZClaim, click here.
[ Article and image provided by Waystar ]
ABOUT EZCLAIM: EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support, and can help improve medical billing revenues. To learn more, visit their website, e-mail them at firstname.lastname@example.org, or call a representative today at 877.650.0904.
Today’s healthcare landscape faces truly unprecedented challenges, which means it’s more important to get the most out of your analyticsto develop more informed, strategic decisions. There’s a deep well of data that each revenue cycle feeds into, which if properly analyzed, can help organizations operate at their most efficient and effective. Here are the four stages of data analytics workflows that are key to developing those actionable insights: A “Trigger,” or the point in your revenue cycle that sets up the call for deeper analysis; “Interpretation” of data to determine root causes and identify appropriate next steps; “Intervention” to improve specific metrics; and “Tracking” of said metrics to chart success in achieving desired outcomes.
So, let’s examine what a successful version of each stage looks like:
Trigger: The trigger occurs when you notice something that needs further investigation. With the right analytics tool you can easily access all of your key performance indicators, financial goals and more, providing the visibility you need into your rev cycle. When something looks amiss or needs improving, you can drill down to the level that shows what’s really going on.
Interpretation: Even a wealth of data amounts to nothing without an efficient way to process and communicate key takeaways. You’ll need to equip your team with access to concise reports, smart visualizations and relevant historical data in order to get them to the insights that drive action.
Intervention: Now is the time to take action. Intervention is ultimately tied directly to your ability to drill down into the data underlying problematic areas of your revenue cycle and clearly communicate takeaways with your team. Success at this stage depends on designing a plan based on your best understanding of underlying issues and the most effective way to address them.
Tracking: Your intervention plan is built on KPIs that naturally intertwine with the way you measure success across your revenue cycle. With proper implementation and tracking, running with the analytics cycle can become a simple addition to your everyday workflow. More than delivering on your initial goals, the true power of analytics is the ability to deliver repeat value on your initial investment.
Wrap Up A strong analytics solution does more than deliver a more fully developed picture of your revenue cycle performance. It provides actionable business intelligence, cuts down on time between analysis and action, and lessens the strain on your IT department.
Waystar is a ‘partner’ of EZClaim, and provides analytics for a practice using their medical billing software. For more details about EZClaim’s products and services, visit their website: https://ezclaim.com/
To learn more about how Waystar can help you harness the power of your data, call their main office at 844-4WAYSTAR, or call sales at 844-6WAYSTAR.
EZClaim is always looking for ways to help our medical billing clients improve. In an effort to further that mission, this month we are kicking off the first in a series called, “What’s Current in Coding.” In this series, we will highlight coding topics, events, webinars, and more, all with the aim of keeping you current in medical billing and coding.
This month our focus came from two articles on coding sourced from the AMBA Newsletter that we feel are hot topics of the industry: “Coding for Group Visits” and the “Telehealth Coding Guide.”
Below you will find full articles and source links.
ARTICLE 1: “Coding for Group Visits”
Many physicians are interested in providing group medical visits. Whether the drop-in group medical appointment (DIGMA), chronic care health clinic (CCHC) or other model is delivered, the coding and billing of these services raise questions about codes and payment policies.
While past instruction on coding for group visits often indicated that physicians should report code 99499 for unlisted evaluation and management services, using this code requires that documentation is sent with the claim to identify the service(s) provided and leaves valuing of the service in the hands of the payer.
No official payment or coding rules have been published by Medicare. However, the question of “the most appropriate CPT code to submit when billing for a documented face-to-face evaluation and management (E/M) service performed in the course of a shared medical appointment, the context of which is educational”, was sent to the Centers for Medicare and Medicaid Services (CMS) with a request for an official response. The request further clarified, “In other words, is Medicare payment for CPT code 99213, or other similar evaluation and management codes, dependent upon the service being provided in a private exam room or can these codes be billed if the identical service is provided in front of other patients in the course of a shared medical appointment?”
The response from CMS was, “…under existing CPT codes and Medicare rules, a physician could furnish a medically necessary face-to-face E/M visit (CPT code 99213 or similar code depending on level of complexity) to a patient that is observed by other patients. From a payment perspective, there is no prohibition on group members observing while a physician provides a service to another beneficiary.” The letter went on to state that any activities of the group (including group counseling activities) should not impact the level of code reported for the individual patient.
Some private payers have instructed physicians to bill an office visit (99201-99215) based on the entire group visit. For compliance purposes, we recommend that you ask for these instructions in writing and keep them on file as you would any other advice from a payer.
Where each individual patient is provided a medically necessary, one-on-one encounter, in addition to the time in the group discussions, there should be no problem in billing for the visit based solely on the documented services provided in a direct one-on-one encounter.
If your group visits include the services of nutritionists or a behavioral health specialist, contact payers to determine if that portion of the group visit can be directly billed by the non-physician provider. This typically would include codes for medical nutrition therapy (97804) or health and behavior intervention (96153).
Other codes that may be applicable are the codes for education and training for patient self-management involving a standardized curriculum (98961-98962). Neither these codes nor medical nutrition or behavioral health therapy are billed by physicians. Physicians must use evaluation and management codes to report these services.
Code 99078 describes physician educational services in a group. Again, it is necessary to contact the payer to verify that coverage of this service is a payable benefit.
As with many services, coding for group visits requires that billing and coding staff do preliminary work with payers to identify desired coding applications.
ARTICLE 2: “Telehealth Coding Guide”
There’s nothing more frustrating than rendering a service and not being paid. Nuanced coding rules are difficult to understand, and physicians aren’t taught this information in medical school.
Still, health care is a business. As business owners, physicians need to know how they’re paid, including what codes to use, what modifiers to append, and what details to document. Brushing up on common coding mistakes helps avoid costly recoupments and denials. We’ve asked several coding experts to provide their best advice on how physicians can maintain compliance and collect all of the revenue to which they’re entitled.
In part 1 of our two-part coding guide, we focused on coding for Telehealth and other forms of remote patient care — important codes for physician practices’ short-term survival as the U.S. continues to grapple with the COVID-19 pandemic.
In times of social distancing, telephone services have become a practical way to improve patient access and prevent the spread of COVID-19. Telephone services are ideal for straightforward problems (e.g., simple rash, asymptomatic cough, medication refills) that require a minimum of five minutes of medical discussion, says Toni Elhoms, CCS, CPC, chief executive officer of Alpha Coding Experts, LLC, in Orlando, Florida. Consider the following codes that Medicare accepts during the current public health emergency (PHE). Commercial payers may accept these codes, as well. Note that once the PHE has concluded, Medicare may only accept G2012 (virtual check-in) for telephone services.
Elhoms provides these tips to ensure compliance:
Document verbal consent, including patient acknowledgment and acceptance of any copayments or coinsurance amounts due.
Only count time spent on the phone engaging in medical discussion with the patient or caregiver. Do not report these codes for conversations lasting less than five minutes.
Clearly document what was discussed, as well as the outcome of the conversation (e.g., medications prescribed, referrals to specialists, additional steps for the patient to take).
Don’t report these codes when the telephone service ends with a decision to see the patient in 24 hours or the next available appointment.
Don’t report these codes when the telephone service relates to a related E/M service performed within the previous seven days or within the postoperative period of a previously completed procedure.
Only provide 99441-99443 and 98966-98968 for established patients. During the PHE, Medicare permits providers to bill G2012 for new and established patients.
‘The best way to operationalize these codes is to set up an edit in the practice management system that pends claims for a manual review to determine whether and which services are ultimately billable, Elhoms says.
Telehealth services In the last few months, providers have adopted Telehealth to improve patient access and generate revenue during COVID-19. Among the services physicians can render via Telehealth to patients with Medicare during the current PHE are Medicare annual wellness visits, new and established patient office visits, prolonged services, smoking, and tobacco cessation counseling, annual depression and alcohol screenings, advanced care planning, and more. Medicare covers more than 200 services via Telehealth, many of which were added for temporary coverage during the current PHE. Commercial payer coverage of these services may vary, and it’s best to check with individual payers, Elhoms says.
Elhoms provides these tips for billing Telehealth services:
Pay attention to audio-only vs. audio-visual requirements. Medicare requires the use of audio-visual technology for certain Telehealth services and permits audio-only for others. Commercial payers also may have specific requirements. For example, physicians can render a Telehealth visit for advanced care planning using audio-only, but they must use audio-visual technology for a new patient telehealth office visit.
Don’t render Medicare’s Initial Preventive Physical Exam via Telehealth. Medicare does not permit it.
Document verbal consent for Telehealth, including patient acceptance of any copayments or coinsurance amounts due.
Use place of service (POS) code 11 and modifier -95 when billing Medicare. Note that commercial payers may require a different POS code (e.g., POS 2 or POS “other”) and modifier.
Document, document, document. Physicians need to prove they met all of the code requirements even when rendering the service via Telehealth, Elhoms says. “Don’t pull in a problem list if you didn’t treat or manage all of those problems,” she adds. “Physicians need to link the diagnosis with the assessment and treatment plan. That’s imperative.” One caveat is that during the current PHE, physicians can bill 99201-99215 rendered via Telehealth based on time or medical decision-making. “The total time in direct medical discussion with the patient is going to be critical,” Elhoms says.
“The best advice I can give anyone doing Telehealth right now is to watch the CMS [Centers for Medicare & Medicaid Services] and commercial payer websites pretty much on a daily basis,” says Rhonda Buckholtz, CPC, CPMA, owner of Coding and Reimbursement Experts in Pittsburgh, Pennsylvania. “The coding of services changes constantly, and practices really need to be careful.”
Online digital E/M services
Though online digital E/M services are relatively new, they also can help practices increase patient access during COVID-19. Here’s how it works: An established patient initiates a conversation through a HIPAA-compliant secure platform (e.g., electronic health record portals, secure email, secure texting). A physician or other qualified health care professional reviews the query, as well as any pertinent data and records. Then they develop a management plan and subsequently communicate that plan to the patient or their caregiver through online, telephone, email or other digitally supported communication.
Elhoms provides these tips to maintain compliance:
Use these codes when physicians or other qualified health care professionals make a clinical decision that would otherwise occur during an office visit. Do not use them for scheduling appointments or nonevaluative communication of test results.
Use these codes only for established patients.
Do not use these codes for fewer than five minutes of E/M services.
Document verbal consent, including patient acknowledgment and acceptance of any copayments or coinsurance amounts due.
Do not report these codes when the online digital E/M service ends with a decision to see the patient in 24 hours or the next available urgent visit appointment.
Do not report these codes when the online digital E/M service relates to a related E/M service performed within the previous seven days or within the postoperative period of a previously completed procedure.
Promoting these services is often the biggest barrier, says Elhoms, who suggests putting up signs letting patients know they can access their provider electronically for non-urgent medical issues.
Remote patient monitoring Remote patient monitoring (RPM) is a relatively easy way for physicians to keep tabs on patients without requiring them to come into the office. Medicare covers RPM for patients with one or more acute or chronic conditions, and commercial payer coverage may vary. During the PHE, physicians can initiate RPM on new and established patients. Normally, Medicare permits it only for established patients.
RPM consists of two forms: monitoring data through either a non-manual or manual data transfer, says Jim Collins, CPC, CCC, a consultant at CardiologyCoder.com, Inc. in Saratoga Springs, New York.
For example, physicians can remotely monitor a patient’s pulse oximetry, weight, blood pressure or respiratory flow rate using a device that transmits daily recordings or programmed alerts. Physicians can purchase them directly from manufacturers or patients can purchase the devices themselves. Collins says patients should look for Bluetooth-enabled devices or ones that include a built-in Global System for Mobile Communications (GSM) transmitter. The former requires an Internet connection, and the latter automatically transmits data to an internet cloud service through an encrypted bandwidth. Physicians can bill for the initial setup, cost of the device itself (when applicable), and data monitoring.
Another example is the self-measured blood pressure monitoring. When patients supply their own blood pressure device that a physician calibrates, physicians may be able to bill for patient education, device calibration, reviewing the data that the patient provides and communicating a treatment plan to the patient or caregiver.
“Monitoring physiologic data on a regular basis substantially reduces hospitalizations, trips to the emergency room and exacerbations of chronic conditions,” says Collins. “It can also be a huge chunk of revenue.”
Collins provides these tips for compliant RPM billing:
Document patient consent. Patients must opt-in for these services.
Document total time spent rendering these services to support time-based requirements.
Know when these codes are appropriate. It’s unclear whether Medicare will pay physicians for monitoring physiologic data derived from internal devices (devices placed within the patient’s body) or data derived from wearable fitness devices.
Only bill 99457 when the provider renders at least 20 minutes of live, interactive communication with the patient or caregiver. “It’s not going to be medically necessary to spend 20 minutes every month on every patient,” Collins says. “Patients could go for several months without physicians needing to do anything for them.”
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