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.
With high deductible health plans on the rise, the recent explosion of telehealth appointments due to COVID-19, and many other factors in play, it’s more important than ever for everyone to understand the life cycle of a medical bill, and how the process works. The healthcare revenue cycle is relevant not only to those who work in healthcare, but to the patient, too.
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:
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 ]
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.
New HIPAA compliance requirements are coming!
In an effort to make the HIPAA Privacy Rule as easy to understand as possible, the Office for Civil Rights (OCR) has come up with a list of rules that clearly explain what Business Associates are now “directly liable” for. As OCR Director Roger Severino explains, “We want to make it as easy as possible for regulated entities to understand, and comply with, their obligations under the law.” The list consists of ten rules that, if failed to follow, can result in penalties and monetary fines.
[ Note: Check out our previous post to access this list ].
As we enter the fourth quarter of the year, you may be wondering what immediate requirements should a Business Associate complete before the end of the year?
One of the most important rules also includes information about Business Associates, and their need for proof of satisfactory assurance when the covered entity requests this of them. Satisfactory assurance is crucial, because it ensures the Business Associate is HIPAA compliant, and therefore, must also be in the form of a contract.
The Satisfactory Assurance contract is oftentimes outlined in the form of a questionnaire, and requires the Business Associate to disclose the date of completion for various compliance requirements.
These include distribution and completion of workforce HIPAA training, implementation and distribution of policies and procedures, Business Associate documentation, and completion of an annual HIPAA Security Risk Assessment.
Are You Prepared?:
If a Covered Entity requests this proof from your organization, would you be able to successfully complete it without outdated completion?
If you are uncertain that your organization would be able to easily and efficiently provide that documentation, you may be facing thousands of dollars in fines for each vulnerability!
HIPAA Compliance Myths:
False: The security risk analysis is optional for small providers: All providers who are “Covered Entities” under HIPAA are required to perform a risk analysis. In addition, all providers who want to receive MU, and MIPS incentive payments must conduct a risk analysis.
False: Our office uses the Cloud, so we don’t need a risk assessment: Even if you have a fully HIPAA compliant cloud vendor, your patient data (ePHI and PII) still must go through all your systems to get to the cloud. So, you are still required to perform technical, administrative, and physical security risk analyses.
False: Our EHR makes us compliant, so we’re fine: While your EHR may provide excellent privacy and security features, it definitely doesn’t exempt you from the HIPAA security requirements.
Live Compliance helps their clients meet the ever changing and complex HIPAA State and Federal regulations. They protect the information they are entrusted with, and ensure their clients pass any Health and Human Services audits. If you are unsure or need assistance, call Jim Johnson with Live Compliance at (980) 999-1585.
Live Compliance is a partner of EZClaim, a medical billing software company. For more details about their solutions, visit their website at ezclaim.com.
Which is the BEST kind of Medical Billing Software? “All-in-One” or “Specialized”?
When considering WHICH medical billing solution they should use, practices wonder which is best, an “all-in-one” solution or specialized software. Well, the following are a few important pros and cons to consider when making a choice between these solutions.
An “all-in-one” system tries to provide a single, comprehensive solution that offers functionality for the major areas of the practice—Practice Management (PM), Electronic Medical/Health Records (EMR/EHR), and Revenue Cycle Management (RCM)—accessed from one central point. It has features like clinical notes, patient information and history, diagnosis and treatments, scheduling, appointment reminders, reports, patient educational resources, as well as a medical billing section.
• Most of what a practice needs is included in the system
• There is no need to be concerned with multiple integrations or vendors
• Tends to have a higher ‘entry’ cost
• Usually designed for the “middle-of-the-road,” therefore sometimes doesn’t properly address specific needs of a practice
• Sometimes, the practice is left paying for additional customizations to fit their particular needs
Specialized medical billing software, on the other hand, is particularly programmed to maintain billing details of tests, procedures, examinations, diagnoses, and treatments conducted on patients. However, many specialized software providers extend their scope to include features like practice management, scheduling, and other administrative and clinical functions (that are generally a part of EHR software systems) by partnering with other specialty software companies—creating a “best-in-class” solution.
• Integrating multiple “best-in-class” software packages—each taking a much more focused approach—creates an offering with much more in-depth capabilities
• Usually are more ‘nimble’ in responding to industry and regulatory changes
• More ’scalable’ in supporting the growth of a practice
• Most of the time the practice has to deal with multiple vendors
Where “all-in-one” solutions offer a wide breadth of capabilities across the business, they usually also lack focus, depth, and sophistication. “All-in-one” solutions are usually only efficient in one area, with the other areas tend to be ‘compromised’ and not fully developed. Then, when it comes to flexibility, they tend to be slow to adapt to changing practice needs.
Specialized software, however, typically offer a more efficient experience, with each ‘component’ streamlined and designed with a specific purpose in mind. Their focus on limiting the software scope makes them flexible and easy to use.
EZClaim—a leading software package in medical billing and practice management—has made it easier for the medical practice to have the benefit of a “all inclusive” solution. They have created the best of both worlds by taking on the responsibility of integrating the “best-of-breed” into a harmonized “best-of-class” offering that allows the practice to pick and choose for their specific needs. The seamless integration of partner products and services ensures the practice does not have to give up robustness and flexibility for a simplified “all-in-one” solution, and it further enhances the practice’s workflow.
As a specific example, one of EZClaim’s partners is TriZetto Provider Solutions (TPS), a provider that seamlessly blends claims processing with revenue management and analytics software, so the practice can get paid faster, and more accurately.
Today, the practice can get the benefit of all the power and ease of use of EZClaim’s medical billing software and all the access and security that is needed when dealing with personal records by using TPS—which includes patient access, claims and denials management, patient financials, and advisory services.
The powerful integration between EZClaim and TPS efficiently adds functionality to the practice. Now the practice can gain deeper insight into the claim lifecycle, and take the proper steps to improve the overall health of the practice. The right ‘integrated’ solution makes all the difference!
So, if your practice needs more confident billing, after payments, and more informed decisions, put the power of EZClaim and TPS to work for your practice with the integrated suite of revenue cycle solutions.
In addition to TPS, EZClaim has tightly integrated a variety of of ‘components’ to be able to offer an “all inclusive” best-in-class solution for a medical practice’s needs: Electronic Health Records (EHR), Clearinghouse, statement and payment services, HIPPA compliance, claims scrubbing, appointment reminders, and inventory management. It has partnered with a variety of providers like QuickEMR, BestNotes, and PracticeFusion [ Click here for an entire list of EZClaim’s partners ].
It is important to note that an “all-in-one” solution does not usually include the Clearinghouse portion that TPS offers. The powerful integration between EZClaim, TPS, and EZClaim’s EMR partners, efficiently adds functionality to ANY practice!
If you are considering the best course of action to meet your practice’s needs, consider using EZClaim by downloading a FREE TRIAL or contact one of their product specialists today to explore all the options for how to best solve your practice’s operational challenges, and grow your business.
For details and features about EZClaim’s medical billing software, visit their website.
There are many commonly misunderstood aspects and nuances with the MIPS program, particularly in how points are earned. For a healthcare practice it can be challenging to know exactly what to do to earn points, optimize the score, and protect their Medicare reimbursements. But, at the same time, the stakes have been raised every year and the final ruling of the program is even more complex than it has been in the past, further increasing the stress, burden and financial risk for a healthcare practice.
The approach a practice takes to report for MIPS will greatly impact the results. Many do not understand, or have awareness of, the different reporting methods available to them. Many Providers erroneously still think that a registry is the only reporting option available to them or that they are required to use a registry. Or, they think that their EHR covers their reporting obligation or that an EHR’s reports satisfy the MIPS requirements. These misperception and erroneous assumptions are detrimental to the financial interests of any practice.
There is a third reporting methodology that has been established and authorized by CMS, called CEHRT, or Certified EHR Technology (software). The CEHRT methodology assists CMS with their need for more valid data submitted through technology and to refocus Providers from merely using technology towards Providers leveraging technology to improve outcomes. Reporting via a CEHRT using software that has been certified by the ONC is a superior approach because it optimizes the points that could be earned and therefore, maximizes Medicare reimbursements for the practice.
Recently an RCM company CEO approached us at Health eFilings with the decision to use six of her clients to conduct a side-by-side comparison of the registry and Health eFilings (CEHRT) methodologies for reporting. In this manner, she intended to validate for herself whether a CEHRT or registry would generate the greatest ROI for her clients. The results of using Health eFilings’ MIPS Accelerator service, on average earned almost triple the points versus a registry for the same year for the same clients.
“Due to limited understanding and guidance, we weren’t aware of the differences of the reporting methodologies available for my clients. We believed there was greater opportunity, but the current registry methodology we had chosen didn’t demonstrate that for our clients.”
Katy, RCM Company CEO
This side-by-side comparison highlights not only that a CEHRT is the superior method of reporting as Health eFilings was able to leverage technology to facilitate the ease, accuracy and completeness of tracking and reporting, but it also maximize a Provider’s MIPS score. Additionally, given the levels of Medicare reimbursements for these practices, the higher score resulted in their earning a positive payment adjustment, which significantly improved their bottom line. And, take note that if the Registry were to perform the reporting for the 2019 reporting period, these practices would not earn enough points to avoid the penalty of negative 7%.
Health eFilings with its proprietary ONC certified software has many advantages over any type of registry:
- Automatically extracts data from any EHR or billing system
- No staff or IT time required to comply
- Benchmarks performance versus peers based on CMS standards
- Proprietary algorithm evaluates 9 million combinations to select best quality measures to optimize score
- Earn 10% in bonus points for the Quality category
- eCQM deciles earn more points than registry deciles
- Almost all eCQM’s have a CMS benchmark versus less than 25% of registry measures
- Electronically submits the data to CMS
And, important to note that it’s NOT too late to comply for the 2019 reporting period as Health eFilings is able to support new clients, but time is of the essence. Reach out NOW if you or your client hasn’t reported for 2019—there is NO REASON to accept the 7% revenue hit.
Now EZClaim and Health eFilings want to ensure you can partner with the only complete, end-to-end MIPS compliance solution that saves you significant time and money. To learn more, click the following link: https://healthefilings.com/ezclaim
[ Article written by Sarah Reiter, Vice President of Strategic Partnerships with Health eFilings ].