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Transcript: Are Your Billing Mistakes Costing Your Patients Money? Hi, everyone, welcome back to Revenue Cycle Decoded where we are cracking the code on revenue cycle issues. Today, I just wanted to riff a little bit on a topic that kind of chaps my hide a little bit, and that topic is billing errors that are costing your patients money or time. So, let’s get started with this topic. The reason that I wanted to talk about this topic today is that I just received a bill from my dentist. Of course, dentists are not fun in the first place, at least not usually, but getting a bill is even more not fun. You want to be billed accurately from your dentist, and unfortunately, this bill was not accurate. So let me tell you a little about it. I went to the dentist and had a cleaning and received the bill. I’m in network. My health plan is in network, the dentist is in network with my plan, I should say, and so they submitted the claim to the health plan. The EOB came back to the dentist with a denial for one of the services that was billed for the reason it cannot be billed on the same day as another service that they also billed for. So, lets’ break that down. If there is an administrative denial on a claim because two services can’t be billed together on the same date of service – that's an administrative denial – you can’t then go and balance bill your patient for that according to your contracts with your payors. Unless, you know, it’s something that is not normally covered by the payor and you’ve received the patient consent to cover that, that’s a different story. You have to explain to the patient that this is a service that isn’t normally covered by the payor and therefore if the patient wants it to be performed, then they would be responsible to pay for it; they sign a consent stating that they are going to be responsible for that service and then you can balance bill the patient. But in this case, it was an administrative denial, the reason being that the code itself – the HCPCS code – specifically states that it cannot be billed with the other service on the same date of service. It’s the intent of the code. So, they had seen the denial on the EOB but they had added back the portion for the denied service onto my patient responsibility and sent me a statement for that amount. Now because I am a certified coder and a certified biller, I immediately questioned, “why am I being billed for a service that was denied?” I looked up the codes so I understood exactly what I was being billed for, and I also looked up their professional association guidelines from the American Dental Association and found that there is indeed a specific guidelines for these two codes which states that because of the code definition of one of the codes, they cannot be billed together on the same date of service and it recommended other codes that can be billed for an exam, for example. Then, I also contacted my payer to make sure that this was an administrative denial and that I was correct that the dentist cannot bill. So, the good news is, I did call my dentist and talked to their front office person who will forward my concern to her manager, but interestingly, when I discussed the issue with the claim, she stated, “We’ve never had somebody bring this up before.” Now that gives me a bit of a pause because that tells me they may be routinely billing these two codes together and patients who are not certified coders and certified billers may not understand the reason that they are getting balance billed and they may just be paying the bill. In other words, they may be paying something that they really, legitimately don’t owe and the fact is that the office is incorrectly billing them and it’s costing the patients money, or at the very least, time, as it did me, to look up the error and inform the office of the error. Hopefully, the next statement that I get, the error has been corrected and the amount has been adjusted off. But this is why it’s important, first of all, for patients to look at their claims and understand what they’re being billed for, but as we all know, patients are not billers or coders. They don’t know the byzantine rules that we live by. That is why, as a practice manager, it falls on you to make sure that your billing staff and your coding staff understand the codes that you’re billing and what’s going on the claims. They need to know any edits that apply to the codes, they need to know any policies, regulatory guidelines, medical policies, clinical guidelines, utilization guidelines, local coverage determinations and articles, all of those different payor guidelines – authorization requirements, anything that has to be met before they will approve the code – your staff needs to understand that. This is why it’s important to have professional coders and billers on your staff or at least someone who is very, very aware of the codes and what their definitions are and all of these things that go into whether or not the code is payable. Otherwise, your patients, who don’t know all of this, could be inaccurately billed and they could be paying you what has been dropped to their patient responsibility when really it should not have been because it was a billing error by the office. This isn’t the first time this has happened to me. A few years ago, I had a screening mammogram done, and according to my health plan, screening mammograms are covered at 100%, so imagine my surprise when I received a bill from the hospital for the screening mammogram for the full amount. When I received the EOB from my health plan, it had denied the service for not meeting medical necessity. Okay, now hopefully, if you have a patient that this happens to, they would question it, they would call up the billing office and say, “Why was this denied because it’s a screening mammogram and it’s supposed to be covered?” and someone would look into it. And that’s what I did. But you may have many, many patients who do not know to do that and would just pay the amount thinking, “Oh, okay it must have been denied for some legitimate reason and I’m just going to pay it.” Or even worse, they don’t pay it, they don’t question it, they just look at the bill and think, “Oh my God, I can’t afford that!” and just don’t pay it. And we know, we have lots of patients that for whatever reason don’t pay their bill and don’t communicate. And in this case, because they don’t question their bill, you may not be looking at it either. So they could end up getting sent to collections for a medical bill that they legitimately do not owe. In my case, once I called, and we dug into the problem, the provider had put a primary diagnosis of essential hypertension on the claim which of course didn’t meet medical necessity for a screening mammogram. they had to go back and re-code and resubmit the claim. These are the kinds of billing errors that can end up costing your patients. It may cost them in time – just the time to look up and call you and sit on the phone and try to figure out what’s going on with the claim because it is wrong and they know it’s wrong or it’s costing them in money because they are paying for a claim that they really don’t legitimately owe, or they are getting sent to collections again for something that they don’t legitimately owe. Just to reiterate for the episode today – how important it is to be an advocate for your patient in the billing process. Not only is it important for us to educate our patients about what their responsibility is and what they will owe for services they will receive, but it’s also our responsibility to be a patient advocate in making sure that our billing is correct to the very best of our ability. Now, I know we are human, things get past us, right? But we need to understand, like I said, the code definitions, the policies, the edits, the requirements, the authorization requirements, etc., etc. We need to understand that. We are the professionals here. We are the ones who are supposed to understand the billing and coding piece of our practices. So I just want to remind you to remind your billers and coders, double check those claims. Run them through the scrubbers, run them through the edits, make sure that the diagnoses make sense, have someone actually looking at the documentation before you are coding and billing out those claims. Make sure the information is correct. This is such an important piece of the revenue cycle, but It’s also so important for your patients. Be your patients’ advocate today. Make sure those claims are correct. Thank you for listening to my rant today. I would like to invite you to join me in the Facebook group Revenue Cycle Decoded or, on LinkedIn, Revenue Cycle for Healthcare Practice Managers and ask any questions that you might have or just join us and add your input. Also you can find me on RevenueCycleDecoded.com where I have a webinar on the different sections of the revenue cycle and what can go wrong that may keep your claims from being paid in each section. That webinar is completely free, it lasts about an hour, it is on-demand so all you have to do is enter your name and email address and you will get instant access to the webinar. And I promise you, it is jam-packed with information and action tips that you can take. I also have a course available now to help you manage and prevent your front end revenue cycle denials and you can find that also at RevenuecycleDecoded.com. That course right now is just $47 for a limited time and it is over 2 hours of content with action items and tools to help you be successful in managing and preventing your front end revenue cycle rejections and denials, so I invite you to come check those out. Join me next time on Revenue Cycle for Healthcare Practice Managers Podcast or on our video YouTube channel. follow me on Facebook at Revenue Cycle Decoded. Thank you!   #revenuecycle #medicalbilling   http://revenuecycledecoded.com   Follow us on social media: YouTube: https://www.youtube.com/channel/UCg2DNvyiGvOhX2Ucv287xOQ   Facebook: https://www.facebook.com/groups/revenuecycledecoded   LinkedIn Group Revenue Cycle for Healthcare Practice Managers: https://www.linkedin.com/groups/14020141/ LinkedIn Company Page:  https://www.linkedin.com/company/revenue-cycle-decoded-llc   Twitter: https://twitter.com/RevCycleDecoded   Podcast: https://www.revenuecycledecoded.com/podcasts/revenue-cycle-decoded

Hi, everybody. In today’s podcast, we’re going to talk about the new 2023 guidelines for evaluation and management codes and how they might impact your providers and your practice. But first, Welcome to the Revenue Cycle Decoded Podcast. My name is Gena Cornett and I help medical practice managers like you get the revenue cycle edge in your practice. I am passionate about helping you learn the skills you need to be a revenue cycle hero, advance your career, and improve your financial results. Let’s dive right in to the 2023 changes to the E/M guidelines. In 2021, AMA released changes to the guidelines for coding office and other outpatient evaluation and management services. The guidelines were intended to reduce the administrative burden placed on physicians. But, because the guidelines were only changed for outpatient visits, physicians and other qualified healthcare providers were faced with managing two sets of guidelines if they saw patients in other settings such as inpatient, critical care, emergency department, or post-acute settings. Now, for 2023, AMA’s CPT® Editorial Panel has approved revisions to the rest of the E/M code section, which will include E/M services provided in these other settings. According to the AMA, the revised guidelines include: New descriptor times (where relevant). Revised interpretive guidelines for levels of medical decision making. Choice of medical decision making or time to select code level (except for a few families like emergency department visits and cognitive impairment assessment, which are not timed services). Eliminated use of history and exam to determine code level (instead there would be a requirement for a medically appropriate history and exam). So to review the changes that will take place: Medical decision making or time will be used to level the E/M code for E/M codes that have levels of services. The provider must include a medically appropriate history and/or physical exam when performed, but the history and exam will not be used to determine the level, and the provider determines the nature and extent of the history and/or physical exam. This guideline brings the E/M codes for hospital inpatient and other settings in line with the guidelines for outpatient E/M leveling. This should, theoretically, lead to less time spent by the physician documenting history and exam and perhaps less cloning of information in the EMR, which is a practice the physician should avoid anyway, although with outpatient documentation in the specialty in which I practice, I have not seen a significant decrease in cloned or “pulled forward” information. Within each category or subcategory of E/M service based on MDM or time, there are three to five levels of E/M services available, but you have to remember that you can’t interchange levels among different categories or subcategories. For example, a new patient outpatient E/M 99202 is not the same thing as an established patient outpatient E/M 99212 – you have to read and understand the definition for each level in each category or subcategory. And the concept of MDM does not apply to the outpatient visit code 99211, which is used most often for an incident-to nurse visit, or to 99281 which describes emergency department evaluation and management services that may not require the presence of a physician or qualified healthcare provider. Medical decision making levels are either straightforward, low, moderate or high; and three elements define medical decision making: The number and complexity of problem(s) that are addressed during the encounter; The amount and/or complexity of data to be reviewed and analyzed; The risk of complications and/or morbidity or mortality of patient management. Let’s look at each of these elements: The number and complexity of problems addressed is pretty straightforward. Keep in mind that just because the documentation includes a laundry list of problems, doesn’t mean all the problems were addressed. To get credit for this element, the physician must document that he or she actually made a medical decision or discussed the problem with the patient or family member. For example, if your patient presents with pain in the knee, just noting that the patient has COPD doesn’t give the physician credit for that problem. The physician would need to document that he or she addressed – in other words, evaluated or treated - the COPD in the encounter and that the COPD increased the amount and/or complexity of data to be reviewed and analyzed, or impacted the risk of complications, morbidity and/or mortality of the patient management decision. Just stating that another healthcare professional is managing the condition also does not give your provider credit for addressing the condition, nor does referral without evaluation or consideration of treatment. For your patients who are hospital inpatients or observation patients, the problem addressed is the problem being managed or co-managed by your provider on the date of the encounter, not necessarily the problem on admission. The next element is the amount and/or complexity of data to be reviewed or analyzed. Data includes any medical records, tests, or other information that the physician must obtain, order, review and analyze for the encounter, including information obtained from multiple sources or interprofessional communications that are not reported separately, and interpretation of tests that are not reported separately. If the physician orders a test, the review of the test result is not counted separately at the next encounter. When tests are ordered during an encounter, they are counted during that encounter – and remember, you can only count a test in MDM if you will not be separately reporting the test. For recurring orders, like monthly prothrombin times, you would count each new result for the encounter in which it is analyzed. Panels are counted as a single test, and pulse oximetry is not considered a test that counts for MDM. If the provider is ordering serial tests during the same encounter, for example, multiple blood glucose tests, the test will only count once. Ordering a test can include those considered but not selected after shared decision-making, for example, if a test would normally be performed but due to risk the physician decides not to order the test for the patient. Remember, that the physician must document his or her medical decision making in this case. Each unique test, order, or document is counted to meet a threshold number. The data element includes review of materials from a unique source. A unique source is a physician or other qualified healthcare professional who is in a different group or a different specialty or subspecialty or is a unique entity, and review of all the materials from each unique source counts as one element. Receiving information from an independent historian, for example, a family member if the patient is a poor historian or unable to communicate, is counted in the data element, as is discussion of management or test interpretation with an external physician or other qualified healthcare professional or appropriate source, as long as you are not separately reporting the discussion with another code. Other appropriate sources could include other licensed practitioners, physicians, facilities or organizational providers such as hospitals, nursing homes, or home health care agencies. social workers, counselors, parole officers, teachers, case managers, lawyers, etc, but not family or informal caregivers. If the provider is including discussion with another healthcare professional in the data element, then a direct interactive exchange must be documented – that means, the exchange of information can’t be filtered through case managers or other persons, and sending chart notes or written exchanges doesn’t count. The third element is the risk of complications and/or morbidity or mortality of patient management. This includes the management options the physician selects and those that are considered but not selected after shared decision making with the patient or family. The physician should include a statement in the note regarding shared decision making by discussion the treatment options with the patient and/or family, discussing the patient and/or family’s preferences and providing education, and explaining the risks and benefits of the management options. If social determinants of health will impact the risk of complications or morbidity from the treatment decision, they should also be documented in the note. This is probably the trickiest element because, according to the AMA, “definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty.” To qualify for a particular level of MDM, two of the three elements for that level must be met or exceeded. AMA has created a table to help physicians and coders in selecting the correct level of MDM. In the same document, the AMA has provided a list of definitions to clarify the terms in the table. I will link to the guidelines where you can find this table and the definitions in the show notes. Now, E/Ms can also be leveled using time. For outpatient visits beginning in 2021, and now for all face to face E/M services that include levels with the exception of emergency department services, it is no longer necessary that counseling and coordination of care make up 50% of the visit in order to count time. In the outpatient office, if the provider’s time is spent supervising clinical staff who perform the face-to-face services of the encounter, the guidelines instruct to use CPT code 99211. Time is the total time on the date of the encounter and includes both face-to-face time with the patient and/or the family or caregiver, and non-face-to-face time which is personally spent by the provider on the day of the encounter performing activities which are typically performed by the provider – it doesn’t include time normally performed by your clinical staff or other separately reported activities. In the case of split visits between a physician and another qualified healthcare provider, time spent by each is summed to define total time. AMA provides tables with the time ranges for each level, and as with the 2021 guidelines, provides prolonged services codes for reporting time that exceeds the maximum range and are included in the document linked in the show notes. As in 2021, CMS will provide its own prolonged service codes. Other changes in the guidelines include deletion of the hospital observation services E/M codes 99217-99220; instead, observation services will be included in Initial hospital care (99221-99223), subsequent hospital care (99231-99233), observation or inpatient hospital care (99234-99236), and hospital discharge (99238-99239) codes. Consultation E/M codes 99241 and 99251 will be deleted to align the four levels of MDM and consultations E/M codes 99242-99245, 99252-99255 and guidelines are revised to remove confusing definitions. The definition of “transfer of care” has been deleted. Emergency department services EM codes 99281-9285 and guidelines are revised; note that time cannot be used to level emergency department E/M services. Nursing facilities service E/M code 99318 is deleted and all other nursing facility E/M codes and guidelines are revised to reflect leveling based on medical decision making or time; Also note a new definition of “multiple morbidities requiring intensive management” is considered at the high-level MDM or initial nursing facility care. Domiciliary, rest home, and custodial care services section is deleted and E/M codes 99324-99238, 99334-99337, 99339, 99340; and home or residence services E/M code 99343 are deleted. These services are merged with the existing home visit codes. Home or residence service E/M codes 99341, 99342, 99344, 99345, 99347-99350 and guidelines are revised to reflect leveling based on medical decision making or time; Prolonged services E/M codes 99345-99347 are deleted; these services will now be reported either with the office prolonged services code 99417 or with the new prolonged service E/M code 993X0 to be used with inpatient, observation and nursing facility services. So, to sum up, if your physicians and providers work primarily in the outpatient world, they should already be familiar with the 2021 revised guidelines. I’ve found in my work that with the introduction of the new guidelines in 2021, E/M levels dipped temporarily as physicians and providers learned the new guidelines, but as they received education and their documentation of their medical decision making improved, E/M levels also improved. If your providers are seeing patients in the hospital or other settings, then the new guidelines should be welcome news. The new guidelines should make coding and billing of E/M services in your practice easier, especially if you have already implemented the 2021 guidelines. And they will mean that we will all be using one set of guidelines, rather than trying to manage and code for two different sets of guidelines. I have found that the 2021 guidelines for outpatient visits were much more intuitive and easier to teach to physicians and easier for physician to understand. To be successful in implementing the 2023 E/M guideline changes, it will be important for practice managers and coders to read up on the new guidelines and put an education plan in place for your physicians. A great place to start is directing your physicians to AMA’s free online webinar on the changes which explains the changes, benefits, and how it will impact the provider’s work, and which I will link in the show notes. I would love to hear your take on the new guidelines and how you feel they may impact your physicians and your practice.  You can find me on Facebook on the Revenue Cycle Decoded group or on LinkedIn on the Revenue Cycle for Medical Practice Managers Group.  You can join me in either place and let me know how you are educating your providers to the new guidelines. I also want to you invite you to my free weekly webinar “Revenue Cycle 101 for the Medical Practice Manager” where we walk through the steps of the revenue cycle, talk about what can go wrong at each step, and I give you some practical actions you can take to improve your cash flow, days in A/R, and profitability. The webinar is held every Wednesday from 12 pm to 1 p.m. Eastern time, it’s a Lunch and Learn, or maybe Breakfast and Learn if you are on the West coast or mountain time. It’s a great webinar and I’

Hi, everybody. In today’s podcast, we’re going to talk about how not investing in your professional development can hurt your career and how you can constantly improve your knowledge and skills as a practice manager.  But first, Welcome to the Revenue Cycle Decoded Podcast.  My name is Gena Cornett and I help medical practice managers like you get the revenue cycle edge in your practice. I am passionate about helping you learn the skills you need to be a revenue cycle hero, advance your career, and improve your financial results.  [Opening music]      Let’s talk about continuing education and learning in this field.  It’s important for anyone to continually learn and improve but it’s even more important in the healthcare space. A mistake you can make which will hold you back in your career and keep you from the success you could achieve is believing that it’s too expensive to invest in your professional development.  Healthcare moves fast and compliance and regulations, billing and coding, reimbursement and payor policies are updated and changed all the time.  It is a constantly evolving world, and if you’re not evolving with it, you will get left behind.  The people who move up the career ladder are those who prove their value because they learn and develop and invest in themselves and their professional knowledge.  There’s a reason highly successful practice administrators and healthcare executives join professional organizations, take courses, earn certificates and advanced degrees – they know that knowledge is power and every bit of knowledge and experience they gain gives them an extra edge on their career path over someone who is complacent, doesn’t improve, doesn’t update, and is willing to just settle where they are or who thinks they already know it all.        Being willing to be a lifelong learner and investing in your own professional development proves to your organization that you are coachable, that you have a growth mindset, and that you are going to bring your best game to the needs and challenges the organization faces.  And you are opening up doors to advancement in your current organization and in future roles.        Many organizations are willing to join you in this investment in yourself, either through n-house training, tuition reimbursement, or paying for your continuing education.  Explore opportunities through your supervisor and your companies' human resources department.  But even if your organization doesn't currently provide financial assistance, it’s still important for you to invest in yourself, either in time or dollars or both.  If money is an issue, there are many low cost and even free opportunities for professional development, and even more expensive offerings can often be financed or put on a payment plan.  Where there is a will, there is a way.        Let’s talk about some of the opportunities to continue your education in healthcare practice management and, of course, my favorite, revenue cycle.  One of those opportunities is formal education.  When I began my career in healthcare many moons ago, it was as a pediatric nurse with a bachelor’s degree in nursing.  After a detour to the mommy track that led to my nursing skills becoming rusty, I decided that the best way to re-enter the workforce and advance my career would be through healthcare management, so I went back to college for a master’s degree in business administration and I specialized in health organization management with an emphasis in medical group management.  You may have come into practice management from a similar clinical background.  Or you may have worked your way up in the medical office to a practice manager position.  If that’s the case, a degree in healthcare administration can help to fill in the gaps between your clinical experience or hands-on experience, and the tools and skills you need to excel in managing the medical practice.  Likewise, many physicians choose to obtain advanced degrees in practice management to understand and participate in the strategic direction and administration of their practice.  I went to school with many physicians who were in the same master's degree program that I was in.  If you’ve obtained an associates or a bachelor’s degree in management, a master’s degree can take you to the next level in your knowledge and demonstrate a commitment to continue growth in your career.  I can honestly say I would not be where I am in my career today if I had not obtained my master’s degree.   It gave me the  tools and the skills that I needed and the knowledge to move forward in my career.      Even if a degree program is not practical for you, many colleges and universities offer certificate programs in practice management or they offer the education needed to site for a certification exam with one of the many organizations that offer certificate programs.     If you already have an advanced degree, or it’s not the right time to go back to school, there are many other opportunities for professional development and education in the field.  Professional organizations such as MGMA, HFMA, AAPC, PAHCOM and others offer certifications either as part of the membership or as a separate offering.  In most cases, you will need to complete required courses and take a rigorous exam and then you will be responsible to complete a specified number of CEUs to maintain certification.  Some organizations have a working experience requirement as well to pass the certification.  These can be great options to level up your knowledge and skills without the cost of an advanced degree.  Different certifications and organizations are more applicable for different types of practices.  For example, MGMA’s certification is especially applicable for practice managers of group practices.  An additional benefit to professional organization membership is the opportunity to meet regularly in chapter meetings to build professional networks and participate in additional education or in chapter leadership.  Most professional organizations also offer annual national or regional meetings with educational offerings where you can obtain CEUs when you attend.     Some non-professional organizations also offer certifications, for example the Certified Medical Office Manager program.  Look for certifications that have good acceptance in the industry and that will provide the knowledge and skills that are applicable to your career.      If you have obtained a practice manager certification, you will likely need to obtain CEUs to maintain your status.  There are both paid and free CEUs.  For example, as part of the AAPC membership, the Healthcare Business monthly publication offers a free CEU when you complete a test on the information in the publication.  Many other organizations offer free or low cost CEUs, or you may obtain CEUs through organization chapter meetings or through employer offerings.      Even if you don’t intend or aren’t able to advance your degree or obtain a certification, you can still be in learning mode.  You can attend regional or national professional organization meetings as a non-member; you can seek out publications on the web such as Physicians Practice or RevCycleIntelligence.  You can peruse payor and government sites which often provide free educational offerings.  Examples include MLN Web-Based Training and Medicare Administrative Contractor training such as NGS Medicare University.        In other words, there are opportunities to advance your knowledge and skills all around you.  I try to make it a priority to learn something new each week, and I encourage you to set aside time each week for your own professional development and growth.   This has been so important in my career.  It's allowed me to advance from Revenue Cycle Manager to a Director of Revenue Cycle Management, and originally from Practice Manager to Revenue Cycle Manager.  But I continue to remain involved in learning and growing my knowledge about practice management as well because it interfaces with revenue cycle in so many ways.     To help you identify opportunities, I have put together a list of education resources for you.  You can access it at revenuecycledecoded.com/education - just put in your email address and you’ll get instant access to the download.      I leave you with a quote from Benjamin Franklin: “An investment in knowledge pays the best interest.”  I would love to know how continuing professional development has benefitted your career.  If you would like to comment, I will put links to my Facebook and LinkedIn groups in the show notes.     I also want to you invite you to my weekly webinar “Revenue Cycle 101 for the Medical Practice Manager” where we walk through the steps of the revenue cycle, talk about what can go wrong at each step, and I give you some practical actions you can take to improve your cash flow, days in A/R, and profitability. The webinar is held every Wednesday from 12 pm to 1 p.m. Eastern time, it’s a Lunch and Learn, or maybe Breakfast and Learn if you are on the West coast or mountain time. It’s a great webinar and I’m certain you will find it valuable. You can go to Revenuecycledecoded.com and find the link to sign up.   With that, I want to thank you for joining me on today’s podcast.  I look forward to serving you on future podcasts.  Until next time, make every day count!  https://www.facebook.com/RevenueCycleDecoded/  LinkedIn:  Revenue Cycle for Medical Practice Managers  https://www.revenuecycledecoded.com/registration-page 

Hi, everybody. In today’s podcast, we’re going to talk about one of the biggest mistakes practice managers make, and that is not involving their team in solving their revenue cycle issues.  But first, Welcome to the Revenue Cycle Decoded Podcast where I help medical practice managers like you get the revenue cycle edge in your practice. I am passionate about helping you learn the skills you need to be a revenue cycle hero, advance your career, and improve your financial results.  [Opening music] Today we are talking about teamwork in revenue cycle. You have heard the phrase, “teamwork makes the dream work” and it is just as true in revenue cycle as it is anywhere else. If you have a practice where you have an incredibly involved team in all aspects of managing the revenue cycle, congratulations! You probably have an extremely high performing team.  However, some of you may be newer in practice management or newer in revenue cycle and you may be trying to take on everything yourself or solve all the problems yourself. First of all, this is a recipe for burnout.  As a practice manager, you wear many hats, and you cannot do everything in the practice on your own. There just aren’t enough hours in the day.  Secondly, if you try to solve all the problems, you are probably not going to come up with the best solutions.  You may waste days or months researching when a team member may already know the answer or a potential solution that would solve the problem. Even if you do come up with a great solution, your team will probably not be invested in making the change, and then you set yourself up for a conflict with your team, or for your team to feel blamed or to undermine your solution.  If you manage a large practice or a practice with multiple locations, departments often function in silos. Departments may not talk to each other or may not share essential information that is needed to solve the issue. For example, you may have an issue happening in your front office processes leading to denials or rejections. The front office may not realize they need to obtain prior authorizations because the payor requirements have changed, but they weren’t made aware.  Or they may have trouble getting authorizations, or payor gateways may not work properly, or payors may be slow to provide authorizations, but the information doesn’t get communicated to the clinicians and providers. It could be eligibility verifications; it could be new people not understanding what they need to do who are still in that learning phase. So, you have these denials and rejections coming across and your accounts receivable folks are seeing them but that information may not be getting communicated up to the front desk.  We’re not necessarily closing that loop.  It could be middle revenue cycle processes such as physicians not understanding what is required in the documentation or not understanding a medical policy or not realizing why backend coders are sending queries, to get the most accurate information in the chart. Again, maybe that information is not getting communicated back to the physicians and the clinicians to close that loop and help them understand what they need to be doing to not get denied.  And, it could be your backend revenue cycle processes. Your accounts receivable or billing staff may be coming across an issue but like we said, it’s not getting reported across the organization and up to other departments so that they can take care of the issue or provide training.  So having department meetings bringing in the key team members together gives them the opportunity to discuss the issues and problems and to share information across departments. You’re also bringing in your problem solvers where they can brainstorm potential solutions, come up with ideas to solve the problems and then you can implement them to see how they work.  Another benefit is that when the team is involved, they are invested in the solution because they are the ones who have recommended the solution. They will be much more inclined to own the outcome and to keep working to solve the problem. And if that solution doesn’t work and they come back to the table again to discuss, then they are creating that solution, they’re owning the solution, and they are owning the process of getting to the solution so they’re going to be much more likely to want to make it work. You’re also letting them know that you value their input and that you are invested in solving the problem for their benefit.  You’re not just trying to solve the problem to get more money for the practice, but you’re also wanting to make their work better, more rewarding, easier for them.  There are few more aggravating things in a workplace for staff than having to work around an issue every single day because either, one, the solutions proposed haven’t really addressed the problem, or they haven’t been allowed to provide their input on how to solve it.  When you’re bringing these team members into talk about the problems they’re facing in their everyday work, or getting denials and rejections resolved, or getting other revenue cycle issues fixed, you’re giving them a voice and letting them know that this problem is important to you, that you want to fix it for their benefit, and you want them to be involved in fixing it for their benefit. When having these departmental meetings, it’s really important to have an agenda with a clear purpose and outline.  You want to ensure the meetings are productive and that you are focusing on the problem to an extent, but then you are really focusing in and honing in on the solution.  So at the beginning of the meeting, you want to provide an outline of the problem and supporting data.  That helps to set the stage for the next steps which will be to outline possible root causes and then brainstorm solutions.  Now the one thing I encourage you to do is that when you are having these department meetings, don’t let them turn into whining sessions where all everyone does is talk about the problem. You have been in meetings that have gone this way where the problem has been presented to the team and then they start talking about the problem and that’s all they focus on.  It becomes really, a whining session. And so you have to stay in control of your meeting.  You don’t want everyone focusing only on the problem and you never get around to talking about the solution.  Sometimes they turn into complaint sessions  like we’re gonna complain about the payors, we hate this payor gateway, we hate this payor… you know what it’s like, if you’ve been in practice management or revenue cycle for very long, you’ve probably heard those particular conversations.  If the meeting begins to take this track, you will have to to quickly redirect to a more productive route, because we want to spend the majority of our time focusing on the solution.  So no more than 10-20% of the time should be spent discussing the problem, and then we want to spend 80-90% focusing on the solution. You will also not want to address too many problems at once. You really only want to pick 1-2 issues where you can identify the problems, identify the root causes and brainstorm some solutions and make a real impact pretty quickly and then move on to another problem or issue in a future team meeting. This helps to keep your meetings focused. It will help to keep your time productive and a wise use of your team member’s time. And finally at the end of the meeting, you should have a list of actions to be done and the team members responsible for carrying out those actions.  Once you’ve been in the meeting, you’ve identified the root causes with your team, or what you think are the root causes, you’ve brainstormed some solutions, and the team has chosen one or two solutions to implement.  At that point, each team member that’s going to be involved in implementing that solution should have an assignment for an action item.  And finally at the end of the meeting you should also have a time and date for a future meeting to review the results because you’re going to want to come back and discuss how the solutions were implemented, were they implemented effectively, were they good solutions or do you need to go back to the drawing board.  So that is my encouragement for you today is to bring that team into your revenue cycle issues so that you can all get around the table and solve it together. This works even if you are small team. Even if it’s just you and your physician.  Having those regular meetings with an agenda to discuss any problems or issues and then focus most of your time on the solution. If you need help getting started with team meetings to iron out revenue cycle issues, I’ve created a very simple sample agenda you can use, and you can download it for free at RevenueCycleDecoded.com\teamagenda.   Thank you for joining me today and I look forward to serving you with more Revenue Cycle Decoded podcasts.

#revenuecycle #medicalbilling In this episode, I discuss four processes that can break down in the front end of the revenue cycle that will cost you time and money. http://revenuecycledecoded.com Follow us on social media: YouTube: https://www.youtube.com/channel/UCg2DNvyiGvOhX2Ucv287xOQ Facebook: https://www.facebook.com/groups/revenuecycledecoded LinkedIn: https://www.linkedin.com/groups/14020141/ Twitter: https://twitter.com/RevCycleDecoded

Hi, and welcome back to Revenue Cycle Decoded where we are making sense of revenue cycle for medical practice managers. Today, I’m talking about meeting medical necessity. So, what exactly is medical necessity and why does it matter when you are coding your claims? Well, our payers consider whether a treatment or service we provide is medically necessary for the patient’s condition on the date of service, and if so, the claim will be paid, assuming we submit a clean claim and everything else on the claim is correct, and the treatment is medically necessary to care for our patient on that date of service. In that case, we would meet medical necessity according to payer guidelines. However, payers also may decide that some treatments are not medically necessary for that patient on that date of service for a variety of reasons, and we’ll look at a couple of examples here in a minute. But for example, if a treatment is considered to be investigational or experimental, in that case, the payer likely will not consider the treatment to be medically necessary and they may not pay you if you perform that treatment for your patient. Another reason would be if we performed a treatment that doesn’t match up with what the patient’s condition is on that date of service. So how does a payer tell if a treatment or a service that we provided matches up with the patient’s condition to determine if it’s medically necessary. Well, the way is ICD-10 codes and CPT or HCPCS codes. As we know, computers understand computer language, they understand numbers. We submit these codes on our claims. Our ICD-10 codes tell the payer why we did what we did on the date of service. This is the diagnosis, or the diagnoses, of the patient’s condition or conditions. And then, the CPT or HCPCS code(s) tells the payer what we did. And so, if what we did matches up with why we did it (the ICD-10 code), that all links up and makes sense, then it meets medical necessity. However, if it doesn’t, then it wouldn’t. So, let’s look at an example here. In the first case, we have a patient who has presented to us with a displaced comminuted fracture of the left tibia. Now, one of the treatments for this, in addition to perhaps surgery, would be placement of a long leg cast. According to best practices, this would be one of the treatments provided for this condition. So, in this case, the ICD-10 code would match up with the CPT code that tells the payer what treatment we provided for the patient’s fracture. That way, the payer sees that this treatment is medically necessary, and they pay for the treatment. But if we submit on our claim an ICD-10 code, a diagnosis of why we did something, and a CPT or HCPCS code, the “what” we did, and it doesn’t match up or link up in the payer’s system, in this case, it’s going to not meet medical necessity and it’s going to get denied. So, what’s an example of this? In this case, we have a patient who has presented with a sprain of the left ankle, and we’ve applied a short leg cast. Well, that wouldn’t usually be the treatment for a sprain, a simple sprain of the ankle, where the physician may recommend wrapping the ankle or putting ice on it, but we generally are not going to cast a sprained ankle. And so, those codes don’t match up – they don’t make sense to go together. And so, your payer system is going to recognize that and deny that claim as not medically necessary if it was submitted this way. Now, what does the payer say? Well, we are going to have to check the payer policy to see what they consider to be medically necessary for a specific condition. And they may not have a policy for everything, but for the things that you are doing in your office, you certainly should be aware if they do have policies. For Medicare, this will be your Local Coverage Determinations or your National Coverage Determinations and also your Local Coverage Articles. Since 2019, Medicare has been moving the ICD-10 codes and the CPT codes into the Local Coverage Articles that often accompany a Local Coverage Determination, so you would want to check both to see which treatments and services are considered medically necessary for a patient’s condition. For a commercial payer policy, you may need to go out to their website and look to see if they have a policy for the particular treatment that you want to perform. And I just want to make a quick mention of unspecified codes. We know with ICD-10, we should be coding to the highest degree of specificity. If we submit so-called unspecified codes on the claim, they may not meet medical necessity in every case. You should be aware of how the payer views submission of unspecified codes on the claim and whether they will pay for those codes or not. Sometimes, it’s simply educating your physicians and providers to document in order to choose the most specific, most granular ICD-10 codes. So that is medical necessity in a nutshell. I hope this has been helpful to you. If it is, please like, subscribe, follow. I’ll be creating many more videos to help you make sense and demystify revenue cycle. I look forward to talking to you soon – have a great day! Follow us on social media: YouTube: https://www.youtube.com/channel/UCg2DNvyiGvOhX2Ucv287xOQ Facebook: https://www.facebook.com/groups/revenuecycledecoded LinkedIn: https://www.linkedin.com/groups/14020141/ Twitter: https://twitter.com/RevCycleDecoded

In the second episode of this multiple part series, we dive into the details of the Interim Final Rule Part 1 for the No Surprises Act. Learn the rules and requirements around the No Surprises Act and how it impacts emergency services, including balance billing, out-of-network coverage, and which services are covered in this episode of Revenue Cycle Decoded where we crack the code on revenue cycle topics for medical practice managers. Revenue Cycle Decoded Follow us on social media: YouTube Facebook LinkedIn Twitter Podcast #revenuecyclemanagement #nosurprisesact #emergencyservices #medicalbilling Transcript: Hello, and welcome to Revenue Cycle Decoded where we are cracking the code on revenue cycle topics for medical practice managers.  In this episode, we are going to continue our discussion of the No Surprises Act, in particular, the Interim Final Rule Part 1 as it applies to emergency services.    So, in our previous episode we provided background on the No Surprises Act. This final rule became effective January 1 of 2022, and so it's very important that you understand what the requirements are and how they impact you, and what you need to do to be compliant. So let's dive into how this Act applies for emergency services.   The No Surprises Act protects against balance billing and out-of-network cost-sharing with respect to emergency services, non-emergency services provided by non-participating providers at certain participating healthcare facilities and air ambulance services furnished by non-participating providers.  Today, we're specifically going to focus on emergency services.   So, the No Surprises Act applies to group health plans and to health insurance issuers offering group or health insurance coverage and to carriers in the Federal Employee Health Benefits program. Specifically for emergency services, the Final Rules applies if a group health plan or a health insurance issuer offering group or individual health insurance coverage provides or covers any benefits with respect to services in an emergency department of a hospital or with respect to emergency services in a freestanding emergency department.  In this case, the plan or the health insurance issuer must cover emergency services and cannot require prior authorization for emergency services including out-of-network services, and without regard to whether or not the provider is a participating provider. Emergency services must be provided without regard to any other term or condition of the plan other than the exclusion or coordination of benefits, an affiliation, or waiting period as permitted under the Code, ERISA, or the Public Health Services Act, or applicable cost-sharing requirements.  The plan cannot impose administrative requirements or limitations on coverage for emergency services received from non-participating providers or facilities that are more restrictive than those applied to participating providers and facilities. And it must comply with the Act's requirements for cost-sharing, payment amounts, and processes for resolving billing disputes.  We'll talk about those requirements in a future episode.    The No Surprises Act limits cost-sharing for out-of-network services, including emergency services and air ambulance services, to the in-network levels that a patient would be expected to pay, and that cost sharing is going to count toward the patient's in-network deductibles and out-of-pocket maximum.  The facility or provider is prohibited from balance billing the patient for any out-of-network amounts over and above the patient's in-network cost sharing responsibility.    According to the Final Rule, emergency services include an appropriate medical screening exam, including any appropriate ancillary services provided by the facility or provider to evaluate if an emergency condition exists. It also includes medical exam and treatment to stabilize the patient regardless of the department of the hospital where that further medical exam and treatment is furnished. In other words, the Final Rule includes pre-stabilization services provided after the patient is moved out of the ER and admitted to a hospital.   The Final Rule is also clear that emergency services provided at an independent freestanding emergency department are also included in patient protections. And the Final Rule categorizes any healthcare facility that is geographically hospital and licensed by the state to provide emergency separate and distinct from a services as an independent freestanding emergency department, even if it isn't licensed specifically as an independent freestanding emergency department. In addition, depending on your state law, if urgent care centers in your state are permitted to provide emergency services, they would also fall under the Rule. If they're not licensed by the state to provide emergency services, then in that case, those urgent care centers would not be included.  So, what is important here is whether or not your state law licenses urgent care centers to provide emergency services.   Now, order the Final Rule, post-stabilization services are covered as emergency services unless four requirements are met.    The first is that the patient is able to travel using non-medical or non-emergency transportation. The second is that the patient receives notice and is able to consent and the patient must be in a condition to receive notification and provide informed consent in order to be transferred to a participating facility for post-stabilization services.  And, finally, any state law requirements must also be met.   So let's talk for a minute about the travel requirement.  In this case, the attending emergency room physician or the treating healthcare provider must determine if the patient is able to travel using non-medical transportation or non-emergency medical transportation to an available participating provider or facility located within a reasonable travel distance.  And, they have to take into consideration the patient's medical condition.  Really, this requirement is intended to address situations where the patient has received emergency services far from a geographic region where any participating providers or facilities are located.  And it would also address situations where a patient in an underserved and geographically isolated community or those with social risk factors related to income and transportation may face additional barriers in obtaining post-stabilization services without some disruption in care.  For example, if a patient is not able to afford a cab to another facility or doesn't own a vehicle or have someone who could transport them to a participating facility.  In other words, the Final Rule is trying to prevent patients in these situations from having unreasonable travel burdens placed upon them to obtain post-stabilization services at a participating facility or from a participating provider.  Now the Final Rule does not define reasonable travel distances, and in fact, has requested comment on what would be a reasonable travel distance and what other factors there might be that could add to an unreasonable travel burden. Now, if the patient does require medical transport to travel, then the surprise billing protections do apply.    So, now let's turn to the second requirement for post-stabilization services, and that is notice and consent. In order for the patient to be transferred to a participating facility or provider for post-stabilization services, notice and consent has to be provided.  And in this case, the emergency room physician or treating healthcare professional must take into consideration the state of mind state of the patient, as well as the effect of any alcohol and the emotional or drug use, including medication that may have been administered while the patient was in the emergency department.  The treating provider or physician must also consider pain as a factor, and whether or not the patient is in the emergency department for a mental or behavioral health episode.  He must also take into consideration any substance abuse impairment, or impairment due to the patient's condition, the reason why the patient presented to the emergency department or any conditions that may have arisen while the patient was there.  But in addition to these factors, the physician must also consider cultural and contextual factors, and those could include a lack of trust due to historical inequities or misinformation regarding consent process or barriers to comprehension of the information in the notice and consent such as accessibility, language or literacy. In addition, the emergency room physician or healthcare provider must make sure that the patient’s civil rights are protected.  The consent cannot be obtained if the patient is subject to undue influence, fraud, or duress, for example, being threatened with restraint.  There must be a reasonable option for post stabilization services, transport, and service provider or facility.    And finally, any state requirements must be met.  Some state requirements may be more restrictive than the No Surprises Act requirements and so, if that is the case, those requirements have to be met in order to meet the standard. In other words, the Final Rule anticipates that post-stabilization notification and consent procedures should generally only be applied in limited circumstances, for example, where an individual knowingly and purposefully seeks care from a nonparticipating provider or facility because they prefer that provider or that facility even though it is nonparticipating with their network.   Now, the Final rule uses the standard of a prudent layperson when deciding if the patient has an emergency medical condition.  Essentially if the patient has acute symptoms of sufficient severity including severe pain that a prudent layperson with average knowledge of health and average knowledge of medicine could reasonably expect that a lack of medical attention could result in putting their health in serious jeopardy or serious impairment of dysfunction, and this does include mental health conditions and substance abuse disorders.    The Final Rule discusses that some plans and health insurance issuers have made a practice of denying claims for emergency services based on the final diagnosis codes.  And some plans and issuers actually auto-deny all claims for emergency services and then the provider or the facility has to appeal and after the appeal is received, then the plan will apply the prudent layperson standard upon reviewing documentation as part of a complete consideration of the claim.  Instead, a denial in whole or in part must be based on a determination that the prudent layperson standard has been met based on all pertinent documentation and it must be focused on presenting symptoms, not solely on the final diagnosis.   In addition, the plan cannot impose a time limit between the onset of symptoms and presentation at the emergency room or restrict coverage because the patient did not experience a sudden onset of symptoms.  And if the plan or issuer provides coverage for any emergency services at all, it cannot deny coverage based on a general plan exclusion that would apply to items or services other than emergency room services, for example, dependent maternity care.  If this episode has been helpful to you, please like and subscribe.  Our next episode will continue our discussion of the No Surprises Act Interim Final Rule Part One, specifically non-emergency services by non-participating providers at participating healthcare facilities. In the meantime, please visit us at Revenue Cycle Decoded dot com where we are cracking the code on revenue cycle topics for medical practice managers.  Also see the links below in our description to join us on Facebook, LinkedIn, or follow us on Twitter.  Thank you for watching.  We'll see you next time. 

Did the No Surprises Act come as a surprise to you in 2022? If so, we've got all the details you need to know. This first episode will provide the background to the No Surprises Act, including why it was enacted. Transcript:Hello, and welcome to Revenue Cycle Decoded where we are cracking the code on revenue cycle topics. Today, we're going to talk about the No Surprises Act, and if you have been in healthcare for any length of time, you have probably been hearing about the No Surprises Act. It's no surprise because it is a big deal. Now if you're still asking yourself "what is the No Surprises Act," it's time to learn because this Act actually went into effect on January 1, 2022 - that's this year! So, let's get started talking about the background and then in future videos we'll dive deep into the details of the Final Rules so you'll understand what's required and what you need to do to be in compliance. Now, group health plans and insurers contract with providers and facilities to provide services to the plan members and those providers and facilities are considered to be in-network, or participating, because they agree by contract to accept a certain amount for their services. There are also nonparticipating providers. These providers are not contracted with the plan and so they can charge higher amounts than the contracted rates that plans have negotiated with participating providers and facilities. These providers are out of network. So, what happens if a patient receives care from a nonparticipating provider even if the patient was at a participating facility and particularly if the patient had no opportunity to choose the provider, for example, in surgery from an anesthesiologist? Well, in this case, the plan could decline to pay all together or the plan could pay an amount less than the bill charges and require greater cost sharing than if the patient had received to care from an in-network provider. In fact, sometimes the costs paid for that out of network provider wouldn't even count towards the patient's deductible or out of pocket maximums. So, in this case, the patient may get a surprise medical bill and these bills could be quite shocking and, in some cases, outrageous. Balance billing is equal to the provider's billed charges minus the amount that was paid by the plan and the amount collected from the patient's cost-sharing portion. Now, this is perfectly legitimate. For example, if you work for a primary care physician and you bill your patient's plan, there may be a cost-sharing portion, the patient's coinsurance, left over after the plan pays its part and you would bill the patient for the difference. A surprise medical bill happens when the patient receives an unexpected bill from the health care provider or facility that occurs when a patient receives medical services from a provider or facility that, usually unknown to the patient, is a nonparticipating provider or facility with respect to the individual's coverage. This could happen if the patient received care at a participating or in-network emergency room but was treated by an emergency room physician who is out of network with the patient's plan. It can also happen if the patient is in surgery or receives other services at in network facility and receives care from a provider who is not in network such as an anesthesiologist or a radiologist reading x-rays; or if the patient receives care from an air ambulance company that is nonparticipating with the patient's plan. In all of these situations, the patient had little or no opportunity to choose an in-network provider but was stuck with the costs from receiving services from the out of network provider. Some of the consequences of these surprise medical bills are devastating. For example, it raises healthcare costs for everybody, but it also exposes patients to significant financial risk. It leads to confusion about medical bills. Patients can certainly be confused when they're receiving a bill from an out of network provider and not understanding why they weren't billed at in-network rates, especially if they went to an in-network facility. Surprise medical bills can also lead to medical debt and even medical bankruptcy and create significant financial hardship, especially in communities exposed to poverty and other social risk factors. Before the No Surprises Act, there were some patient protections put into place, for example, the Public Health Services Act required that group health plans or health insurance issuers offering group or individual Health Insurance coverage had to cover emergency services without requiring prior authorization and without regard to whether the Health Care provider was in-network and they can't impose any administrative requirements or limitations on benefits for out of network emergency services. In addition, they were required to pay a reasonable amount quote unquote before a patient became responsible for balance billing. However, this Act did not prohibit balance billing and it only applied to emergency services. And let's just say those reasonable surprise bills -- well, from a patient perspective, they weren't so reasonable. Now, many states have also enacted surprise medical billing rules, and in fact, right now over 50% of the states have some protections in place to protect patients from surprise medical bills but the laws vary dramatically. Some states offer very little protection, while other states offer comprehensive protection, with a lot of states somewhere in between, and this patchwork of consumer protections is limited in its ability to address surprise medical bills from out of state providers and typically only applies in individual and group Health Insurance coverage, not self-insured group health plans sponsored by private employers. Enter The No Surprises Act. Congress recognized that this was a problem for patients and for healthcare costs overall and so The No Surprises Act was put into place to protect participants, beneficiaries, and enrollees in group health plans and group and individual Health Insurance coverage from surprise medical bills when they receive emergency services, nonemergency services from nonparticipating providers at participating facilities, and air ambulance services from nonparticipating providers under certain circumstances. Now looking at this list, you may think this doesn't apply to you but wait and see as we dive down into the final rules and you'll find out that, in some cases, yes, it does. In our next video, we are going to dive deep into the No Surprises Act Final Rule Part One. We'll give you all of the details so that you can understand what's required and what you need to do to be compliant. Be sure and visit us at RevenueCycleDecoded.com where we are cracking the code on revenue cycle topics and be sure to like and subscribe to our channel. Thanks for watching! See you next time!