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 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 revenue this 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.
RESERVE YOUR PLACE NOW!
ABOUT THE PRESENTERS:
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.
EZClaim Launches EZClaimPay, a new feature in its medical billing software that makes credit card processing painless!
EZClaim, a company with the mission of elevating its clients to stay in front of the ever-changing landscape of medical billing, announced today the launch of its credit card processing feature and service called, EZClaimPay.
EZClaim released the product in August 2020 as a solution to the ever-changing landscape of payment reconciliation. It was cited by customers as a timely response to a ‘pain point’—credit card payment processing—another example of EZClaim’s devotion to their mission.
Dan Loch, VP of Marketing commented that “EZClaim’s goal continues to be making life easier for medical billers at practices and billing firms. EZClaimPay is just one more feature within our mission of living up to that goal.” This feature will help companies get in front of the changes in medical transparency that are coming soon.
EZClaimPay provides for consolidated reconciliation (Payment reports; Chargeback management; and Reconciliation reports) and a single point of contact for support (Hardware; Software; and Payments).
EZClaim has developed a robust payments platform—tightly integrated with their software and support—to make accepting credit cards for payment PAINLESS! EZClaimPay makes software and payments better together.
For more details about EZClaimPay, view this web page: https://ezclaim.com/ezclaimpay/
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 email@example.com or call a representative today at 877.650.0904.
The 2020 MIPS reporting is already half done, and given that MIPS (Merit-based Incentive Payment System) is a points-based program, the goal is to earn as many points as possible to avoid this year’s 9% penalty and potentially even earn a positive payment adjustment. However, earning the 45 points necessary to avoid the penalty for the 2020 reporting period will be no easy feat. With over half of the reporting period already behind us, it is imperative you ACT NOW so you don’t find yourself in position later in the year that you can’t recover from in terms of earning points.
With all the complexities and nuances of the program, its challenging to know what you can do to impact your score. Here are three critical actions to take right now so that you will still optimize your ability to earn points for the 2020 reporting period:
1. Focus on the Quality Category
There are various points available within each of the categories and the Quality Category has the most points associated with it. Based on a number of factors, the category is worth anywhere from 45 to 85 points. This is a critical category to be focused on throughout the year, so now is the time to ensure that you are tracking all relevant data so that it can be properly reported on within your submission.
2. Understand the Timeframe Requirements
Two of these categories, Promoting Interoperability and Improvement Activities, have timeframe requirements where you must perform for a minimum of 90 continuous days. These are not easy categories in which to be successful and so if you wait too long in the year you will find it impossible to put the right actions in place in order to complete the activities necessary to earn any of the points in these categories.
3. Choose the Right Reporting Methodology
Not all reporting methodologies are the same and the reporting methodology you select has a significant impact on the points you could earn. Additionally, there is strategic maneuvering that can be done throughout the reporting period with exemptions and reweighting of points that can set you up to optimize your performance and your score. Therefore, you must select a reporting partner that will help you earn the most points available and leverages technology to facilitate the ease, accuracy, and completeness of tracking and reporting to maximize your score. Reporting via a CEHRT, like Health eFilings, is the best approach because it optimizes the points that could be earned and therefore, maximizes Medicare reimbursements.
Health eFilings is a certified EHR technology (CEHRT) and the national leader in automated MIPS reporting. Their cloud-based ONC certified software fully automates the reporting process. Because Health eFilings’ service is an end-to-end electronic solution that doesn’t require any IT resources, administrative support, or workflow changes from you, the practice will save significant time while maximizing its financial upside.
To learn more about how to properly perform your 2020 MIPS reporting, contact EZClaim’s partner, Health eFilings, so they can help before its too late!
For details and features about EZClaim’s medical billing software, or general information about the company, visit their website.
[ Written by Sarah Reiter, SVP Strategic Partnerships, Health eFilings ]
Concerned about the claims process during COVID-19? Well, Alpha II remains on the forefront of the coding and billing changes during the COVID-19 public health emergency (PHE). They understand this is a confusing time for providers, practices, and hospitals.
Now more than ever, practitioners are relying on the revenue brought in by accurate claim submission. So, if you would like more up-to-date details, join us for our Bring Revenue Integrity to the Claims Process During COVID-19 webinar on June 16th at 1 p.m. ET, and learn how to recover revenue based on the waivers allowed under the PHE. Click here to register for the webinar.
We have also compiled a comprehensive COVID-19 billing and coding FAQ document of questions received during our highly-attended webinar series. Click here to download the resource.
As guidelines for coding and billing of COVID-19 services are revised regularly, Alpha II is implementing these critical changes to regulations and coding guidance—almost immediately.
Alpha II empowers precision across the revenue cycle process so you can experience reduced cost, improved cash flow, and increased revenue. Through its software-as-a-service (SaaS) solutions, Alpha II supports coding, compliance, claims editing, value-based quality reporting and revenue analysis.
For more details about how Alpha II’s solutions can keep your coding, billing, and editing current, view our website or fill out our contact form to ask us a specific question.
Alpha II is a preferred partner of EZClaim, and their software is integrated into our medical billing software. For detailed product features or general information about EZClaim, visit our website at ezclaim.com/