Managing Complexities of Behavioral Health Credentialing

Managing Complexities of Behavioral Health Credentialing

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.

 

TriZetto Provider Solutions is a partner of EZClaim and can assist you with all your coding needs. For more details about EZClaim’s medical billing software, visit their website, e-mail their support team, or call them at 877.650.0904.

[ Contribution: The TriZetto Provider Solutions editorial team ]

New Year, New Codes: Medical Coding Changes For 2021

New Year, New Codes: Medical Coding Changes For 2021

With a new year comes new medical coding changes.

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.

 

TriZetto Provider Solutions is a partner of EZClaim, and can assist you with all your coding needs. For more details about the EZClaim medical billing solution, visit their website, e-mail their support team, or call them at 877.650.0904.

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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. 

[ Contributed by TriZetto Provider Solutions Editorial Team ]

Latest Best Practices for Medical Offices During COVID-19

Latest Best Practices for Medical Offices During COVID-19

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:

Eligibility Woes: The Impact of COVID-19 on Insurance Coverage
Adapting denials management to protect and retain revenue
Healthcare Huddle: How to Manage Telemedicine & New Challenges during the New Normal

 

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 sales@ezclaim.com, or call a representative today at 877.650.0904.

‘All-in-One’ or ‘Specialized’ Medical Billing Software? Which is Best?

‘All-in-One’ or ‘Specialized’ Medical Billing Software? Which is Best?

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.

ALL-IN-ONE:
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.

PROS:
• Most of what a practice need is included in the system
• There is no need to be concerned with multiple integrations or vendors

CONS:
• 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 SOFTWARE:
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.

PROS:
• 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

CONS:
• Most of the time the practice has to deal with multiple vendors

 

CONCLUSION:
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, but 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.

Clearinghouses – Simply a Pass-Through Portal?

Clearinghouses – Simply a Pass-Through Portal?

AMBA 2019 National Conference Session Recap

Written by Stephanie Cremeans of EZClaim – AMBA 2019 National Conference Session Recap

I recently attended a breakout session of a seminar with a slide titled: “Clearinghouses are not Simply a ‘Pass-Through’ Portal.” With my role as a software support specialist, I immediately tensed up and thought about how inaccurate this statement is – I hear from clients that think that the software or the clearinghouse has changed their data, but that simply isn’t how it works. Well, kind of not how it works. You know that nothing in medical billing is as simple as it seems! Depending on how your practice management system works and depending on your understanding of how electronic claims are filed this may or may not be a valid statement. While I’ve always described a clearinghouse as simply a “pass-through” for your claims this seminar got me thinking about how much more a clearinghouse is! Let’s explore a little, starting from entering your claim into your PM system and clicking send.

The first piece of the puzzle is understanding what your PM system is (or isn’t) doing with the data. You’ve entered the claim data and you are ready to send your claims to the clearinghouse, but how is that data transferred?  There are 2 typical formats – Print Image or ANSI 837. All claims being sent to payers must be in the ANSI 837 format, following specific guidelines for submissions. Although some clearinghouses are no longer accepting Print Image files, some do. In this instance, the PM system creates a snapshot of a claim form which requires the clearinghouse to move data into the correct fields for claim submission to the payer via the ANSI 837. Preferably, your PM system can create the ANSI 837 file for submission to the clearinghouse. The biggest advantage here is that you can typically view the file and the clearinghouse will not be changing anything before submission to your payer. If your PM system cannot create an ANSI 837 file I would consider upgrading or find a new solution.

So that’s it, right? If you have a system that creates a Print Image the clearinghouse is more than a pass-through and they “change” your data. If you send an ANSI 837 file, it simply passes your file along. Well … while this may be true, it’s really only part of the story, and you are potentially missing out on some pretty amazing resources that are at your fingertips! In addition to submitting the claims to your payers, they can scrub claims for common errors, confirm batch receipt and acceptance, provide claim level updates of accepted/rejected claims, and provide electronic remittance advice for auto-posting insurance payments. In addition, many offer additional services (for an additional fee) that can integrate with many practice management systems like integrated eligibility, determine deductibles and co-pays, patient cost estimators, claim status inquiry, patient statement processing, and printing services for your paper claims.

I’m working hard to remove the phrase “just a pass-through” from my definition of a clearinghouse. Once you have submitted an 837 file, they are still doing so much more than simply passing along the file.

EZClaim partners with TriZetto Provider Solutions but is designed in such a way that it will work with any clearinghouse a customer would like to use. The white-glove support team is even there to help set up the connection if needed.

We hope you enjoyed this AMBA 2019 National Conference Session Recap by EZClaim. Click here to view our blog page for more interesting and useful articles.