Feb 10, 2022 | Partner, TriZetto Provider Solutions
While the No Surprises Act aims to address many issues involved in the patient price transparency process, a lot of attention will be put on out-of-networks charges. Many of the provisions will address how patients will be relieved of surprise medical bills from services that were rendered by providers outside of their insurance networks, and providers are wanting to know how to prepare for potential changes in their revenue. We detail how CMS has planned to address out-of-network payment disputes for emergency situations, as well as situations when services were non-emergent.
Emergency Out-of-Network Services
Providers will begin to see differences in reimbursements for emergency out-of-network claims. These will be paid using a ‘Qualified Payment Amount’. Payers are instructed to use different methods to determine the payment amounts, which will vary by the location of the service.
Dispute Resolution
Providers will need to be prepared to review these claims to see that they were paid appropriately or if there is a need to dispute the claim. If a dispute is in order, CMS provides a portal to initiate a dispute. Dispute resolution follows a strict timeline that goes as follows:
- Submit Claim
- After claim submission the health plan has up to 30 days to pay or deny
- Negotiate Payment
- Next, payers and providers have 30 days of claim payment or denial to negotiate
- Initiate Dispute
- Providers then have within 4 days of end of negotiations to initiate a dispute using the CMS Portal
- Select Arbitrator
- If no agreement come from the negotiations, one will be selected by CMS within 3 days
- Submit Dispute
- Within 10 days of arbitrator selection, provider and payers submit documentation and offer for reimbursement
- Arbitrator Decision
- The arbitrator then decides which offer to be paid within 30 days of the dispute
- Final Payment
- And final payment will be made within 30 days of the arbitrator decision
Non-Emergency Out-of-Network Services
The No Surprises Act prescribes that out-of-network patients will receive good faith estimates prior to receiving services at medical facilities. The act covers self-pay and uninsured patients, but may also include patients whose health plan does not cover the services to be provided, as well as patients who have benefits but are opting not to use them. Patients who receive a bill for services that differs from the estimate by more than $400 will have up to 120 days from receiving the bill to dispute the charges. Additional rulemaking will be forthcoming to define how provider and payer systems should interact to provide cost information for the estimate.
Keep abreast with updated regulations and the key points of the No Surprises Act (NSA) that could impact your revenue cycle by visiting TriZetto Provider Solutions’ designated landing page. Subscribe to NSA news updates and explore solutions that equip you to have informed conversations about financial responsibility and eligibility.
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.
Feb 9, 2022 | DocVocate, Partner
Denial management has been a thorn in the side of provider RCM teams forever. And unfortunately, despite expanded EHR use and claim coding improvements, denial rates have continued to rise into the pandemic; from 9% in 2016 to 10.8% mid-pandemic in 2020.
Cost To Rework Claims
To make matters worse, the average cost of reworking denials ranges from $25-$118 per claim. As a result, over 60% of denials are never resubmitted! Here’s why:
- Lack of A/R Specific Software: Payer and EHR variability has forced A/R into manual workflows
- Staff Cost: Cost to retain skilled A/R follow up staff
Keys To Optimizing Denial Management
The good news is, modern software tools are easier to build and here to help provider billing teams. Historically, only large hospitals and payers had access to the most advanced technology, but that’s changing rapidly. Here are a few A/R follow up areas where modern software can help.
Auto-Triage of Claims
The current standard for all billing teams is to assess each claim one-by-one. Typically, it’s an “ERA by ERA” assessment that often requires further digging to really determine the correct action. However, payer claim decisions are pattern-based. With modern tools that combine these patterns with your preferred triaging, the software can triage claims in batches. This both removes the repetitive process of claim triage and optimizes the proper action decision.
100% Digital Appeals
Even after choosing to appeal a claim or send a medical record, the process of building an appeal letter, filling out a payer form, and then submitting it back to the various payers is extremely time consuming. Some teams report that it takes 35 minutes per claim!
Finding the right language to best appeal the denial is challenging on its own. What worked and what didn’t work — and why? Billing agents are often left to themselves to figure this out. From there, actually submitting the appeal via postal mail, fax, or payer portal is both time consuming, costly, and often requires a different team to touch the appeal.
Having a solution that turns this entire build and submission into a single, digital process for all denial types and payers is the only way to solve this major pain.
Team Performance Tracking
Without a digital A/R follow tool, described above, billing team managers are left to track their team’s performance through the use of onerous spreadsheets and difficult to assess reports. Managers rely on their team members to train each other and report back any difficulties they might be experiencing. This leads to real gaps in performance assessment and, ultimately, the ability to help their teams succeed.
Having a digital A/R solution fixes that. The need for a real-time dashboard that provides these KPIs, along with real-time alerts related to individual agent performance, is the way forward.
Real-Time Denial Trends AND Alerts
Finally, as mentioned earlier, denials happen in patterns. The challenge is, those patterns vary by payer, provider, region, and specialty. And they change over time too! So, these patterns are difficult to track manually. Each pattern change has immediate downstream effects that can lead all the way back to the providers themselves, with annoying code corrections and medical records requests.
A modern A/R solution that is dedicated to sharing these patterns via a real-time dashboard is the key. Not just a static dashboard with denial statistics, but in-app and email alerts that indicate an important change in a pattern. That aspect is especially important, because all billing agents are extremely busy and are bogged down by task after task. A smart platform that informs you of the most important information without any effort from you is required.
This is an exciting time for provider billing teams. At DocVocate, our team is passionate about helping provider billing teams. We’ve spent considerable time thoughtfully building our platform, Appealio, just for you. New tools are on the way to help!
If you found this helpful and would like to discuss further, please feel free to reach out to us at info@docvocate.com.
Jan 15, 2022 | EZClaim
As we move into the new year, we wanted to take a moment to share the most popular articles of 2021. We’ve ranked them below so that you can be sure that you haven’t missed out on any resources that EZClaim clients have found useful in the past year.
Here are the most popular blog posts of 2021:
This interview was by far and away the most popular blog post over the past year. Jennifer and Maura provide some great insight and best practices, including their “investigative” approach to medical billing and the problem-solving skills that are necessary. Here is a summary of that article:
Are you working in the medical billing industry as a biller or an owner of a billing company? If so, the key medical billing insights and best practices that came out of our interview with Maura Jansen (VP of Operations) and Jennifer Withington (Director of Revenue) at Missing Piece Billing & Consulting Solutions will be very valuable for you to consider.
Jennifer, an expert in understanding the problem-solving techniques and the investigative nature of medical billing, offers insights that both educate and inspire. Maura, an executive member of the billing community, also added an important perspective about EZClaim’s medical billing software. The following are some highlights from our interview.
Getting patient billing information quickly can be a big pain point, so it makes sense that this article was among the most read of the year. We walked through some tips and ticks for saving time including the EZClaim eligibility feature:
Can you add up the number of hours your billing team spent during any given week or month waiting on-hold with insurance companies to get patient billing information? Does your staff invest hours of their valuable time seeking out the smallest of details to get paid? Are you aware that integrated eligibility, through EZClaim’s medical billing software, can reduce that time on-hold to a fraction of the total?
It is estimated that the average biller can spend up to 2-hours on-hold just to get an insurance company on the phone. Add to that an average of 10 – 15 minutes to talk through a patient and most companies will only address one or two patients at a time.
In this interview with a medical billing expert and co-owner of Elite Billing Resolutions, Vicky Greenwood, we talk about dealing with the challenges in owning a billing company, some important skills that every medical biller needs, and the value of choosing the right medical billing software. In our time speaking with Vicky, we focused on topics that will aid, contribute, and help grow the skills of the medical billing community. We at EZClaim believe in highlighting the best practices in the industry and sharing those with the larger community. We encourage you to consider these insights, and then let us know what topics you would like to learn more about.
Double data entry is frustrating. Luckily there is a better way—integrating your EHR with EZClaim.
Are you or your staff having to enter every patient into your EHR program and then again into EZClaim? There is an easier way! Integrating your programs will put an end to duplicate data entry, saving your practice time and money!
So, what exactly is an interface and how does it work? An interface is a way for two programs to share information. For EZClaim clients, the interface can be set up to share data from your EHR program to EZClaim. Your EHR can give you specifics on how to send the data to EZClaim.
Minimizing and preventing claim denials is a challenge that providers are increasingly running up against. We put together four strategies to address this growing problem:
Reducing claim denials has long been a challenge for providers. In the worst case, denied claims end up as unexpected—and sometimes unaffordable—bills for patients. The challenge only seems to be growing. A recent survey conducted by the American Hospital Association (AHA) found that 89% of respondents had seen a noticeable increase in denials over the past three years, with 51% describing the increase as “significant.”
Minimizing loss will be top of mind for providers as the COVID-19 pandemic continues to put a strain on their resources, and minimizing or preventing denials will need to be a core part of that strategy. With that in mind, we’re offering four tips to help guide revenue cycle strategies for better denial reduction in 2021.
There you have it, the most popular posts on the EZClaim blog in 2021. We look forward to keeping you up to date on everything medical billing in the new year!
Jan 6, 2022 | Live Compliance, Partner
Have you performed and identified your organization’s vulnerabilities with a Security Risk Assessment this year?
We understand that achieving and maintaining compliance is a delicate matter as it requires auditing, constant supervision, good staffing, adequate policies, and procedures, along with excellent reporting and investigation of any issues.
The process of assessing and maintaining compliance to any standard is the same, irrespective of the industry but especially when HIPAA compliance is required:
1. Start with a complete understanding of all the rules that you are expected to follow.
2. Establish internal policies and procedures to ensure your organization follows the rules.
3. Regularly check and assess whether or not your organization is following the rules.
4. Address issues whenever you discover the rules are not being followed.
5. Document everything.
6. Perform accurate and thorough Security Risk Assessment(s)
Are you unsure or not clear on what your organization is required to do?
THINGS TO CONSIDER:
● A Security Risk Assessment will target vulnerabilities related to what is potentially exposing Protected Health Information. Correct any potential risks identified within your Technical, Administrative, and Physical deficiencies.
● A Security Risk Assessment should be completed at least twice a year to target vulnerabilities
● Your policies and procedures should be thorough and accurate and reflect the Corrective Action Plan that is determined by the Security Risk Assessment and remediation steps should be taken to correct any deficiencies or vulnerabilities found.
● Workforce training should reflect the organization’s HIPAA Policies and Procedures
Would you like to schedule a compliance team meeting phone conference? If so, please contact support@livecompliance.com or at (980) 999-1585, and one of our compliance support team members will reach out to you.
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.
Dec 30, 2021 | Partner, TriZetto Provider Solutions
Are You Getting the Most Out of Your Credentialing?
Enrollment status can greatly affect the dollar amount payers reimburse, and some specialists are opting to go out of network. We weigh the pros and cons of this trend to explain why it may make sense for select providers.
Did you know that reimbursement is directly tied to credentialing? It’s all in the details, and enrollment status can greatly affect the amount payers reimburse. When enrolling as an in-network provider, payers and providers decide on an agreed-upon rate. However, a physician can decide to forgo a traditional contract with a payer and instead choose to be labeled as “out of network”. Of course, they will still be listed as a provider, albeit without the stated reimbursement rates and payment security that comes with having a contract in place.
If you are wondering why this option is appealing to some physicians, just look at common treatments the average healthcare consumer may be familiar with. Every year, most adults and children visit their local eye specialist for an annual exam. An optometrist performing a routine eye exam will most likely receive optimal reimbursement. This service is covered by insurance in the majority of cases and the reimbursement will be within a standard range. However, if this same patient is then referred to an ophthalmologist for advanced cataract surgery, for example, the odds of insurance covering this procedure are less likely. From the standpoint of the ophthalmologist, his credentialing specifics may not matter too much, since he will be paid regardless and the patient is most likely assuming that they will have a large out-of-pocket cost. When all is said and done, the ophthalmologist is set up to take home more than if he was listed as an in-network option. Looking at it through the eyes of the surgeon, it would not make sense financially to be credentialing with payers the traditional way.
The benefit of being in-network boils down to the contracts that determine what providers will be paid. When a provider works with a payer, an agreed-upon rate is determined. If paperwork is filled out correctly and claims are submitted on time, there will not be too many surprises when the time comes to be reimbursed. A provider will know what to expect from a particular service. This process works best for providers that like the security of having a contract in place. However, these contacts with insurance companies often result in providers being paid less than fair market value. The truth of the matter is that fair market value may often be more than payers are willing to pay.
It’s not uncommon for family doctors, or eye care professionals that deliver routine exams like the example mentioned above, to work in-network because the margins are small. For highly specialized services, often considered elective and not covered by insurance, the potential for large reimbursement grows significantly. For instance, let’s say a plastic surgeon performs surgery in their own surgical suite. The procedure may cost $14,000. Through payer reimbursement as an in-network provider, the surgeon receives $4,000. However, if the surgeon is considered out-of-network, they have the ability to negotiate rates, meaning much more could potentially be earned. From the patient’s standpoint, it’s not uncommon for a patient to shop around and expect to use an out-of-network provider anyway for these types of highly specialized services.
When it comes to gaining credentials, an out-of-network provider will not have to go the traditional credentialing route. This question arises: Is it smarter for medical professionals to perform their services as in-network or out-of-network providers? The truth is, a lot of doctors do not actually realize they have the ability to negotiate. It all comes down to how they want to pay, and the power lies with the provider.
Credentialing is complicated, and it helps to have the right partner in place to navigate the path to credentials. TriZetto Provider Solutions (TPS) has experienced credentialing experts in place that can help with every aspect of the process. Visit our TPS partner page to learn more and request a demo.
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.
