Transcript Third Party Reimbursement Training

Third Party
Reimbursement
Training
Julia Hidalgo, ScD, MSW, MPH
Positive Outcomes, Inc.
Harwood MD
www.positiveoutcomes.net
[email protected]
(443) 203 - 0305
Planning Committee
 Aubrey Arnold
 Gayle Corso
 John Eaton
 Theresa Fiano
 William Green
 Deidre Kelly
 Syd McCallister
AHCA
 Heidi Fox
HRSA HAB Project
Officers
 Johanne Messore
 Yukiko Tani
TPR Trainers
 Curt Degenfelder
 Marilyn Massick
 Michael Taylor
Ground Rules
 I do not represent
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HRSA, CMS, or AHCA
Let me know if you do
not understand
We can share our
feelings at the end of
each section
You will be rewarded for
staying awake
Shut off your electronic
devices
A 15 minute break
means 15 minutes!
Overview of Today’s Session
 Overview regarding organizing patient/client
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charts, basics of billing, developing billing
systems
Additional training modules and materials
are available on website
Real life examples will be used
Resources for more in-depth information are
identified
Each section includes training and
discussion
Train the trainer approach is used
Please follow-up by email with additional
questions
Focus of the training is on beginning to
intermediate skills
Advanced training and TA are available
What is third party reimbursement (TPR)?
Patient
1st Party
$
services
Insurer
Medicaid
Medicare
3rd Party
Provider
2nd Party
$
TPR is receiving payment from a source other than the patient for
services provided to patients by a provider. This other source is
the “third party”
Constructing
an Effective
TPR Strategy
HRSA Grant Funding Versus TPR
 The CARE Act is considered by the HIV/AIDS
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Bureau to be the payer of last resort
 This requirement is subject to audit
 CARE Act grantees have been audited
Grantees and subgrantees should not rely on
grant funds as their sole source of revenue
 HRSA grant funds are finite because they are
capped in annual appropriations
TPR is driven by patient service and volume
 Funds from TPR should be used in addition to
HRSA grant funds
The Role of a Grantee’s Sponsoring Organization
 Communicate the availability and value of TPR
 Grantees and subgrantees (i.e., contractors) should
agree upon billing and collections responsibilities
and procedures
 Grantees should request periodic accounting of
collected TPR payments, as appropriate
 These payments should be reported as grant
income
 Grant income should be retained by direct service
provider grantees or contractors
 Grantees should develop and implement clear,
adequately documented processes for CARE Act
invoices for Title I and Title II
Documenting
CARE Act and
Other Funded
Services
Health and Case Management Record Basics
The record is the core element of a visit or
other unit of service
 It is a systematically organized record of a
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patient’s total care
Everyone who records progress of care in the
record should follow the same note writing format
Policies and procedures dictate its organization
and use
Creates a verifiable record of services provided
for third party payers and other interested parties
(QI, accreditation, etc.)
Health and Case Management Record Basics
 The record is the primary instrument for
planning care
 Forms the basis to bill and pay for care
 Documentation in the record can be reviewed by
third party payers
 Records are legal documents that assist in
protecting the interests of the patient, facility,
and providers
 They are considered to be more reliable than an
individual’s memory about events
 They can be used in court or for other legal matters
 They can protect you in a law suit
Record Documentation
 Documentation provides the who, what,
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when, where, why, and how of patient care
Regardless of the complexity of
documentation, records must be
comprehensive enough to meet regulatory,
licensing, accreditation, legal, research,
and patient care needs and purposes
Record notes must be comprehensive
enough to support evaluation and
management code assignment
Record Contents
 Date and time of service
 Place of service
 Chief complaint/presenting problem
 Objective findings
 List of tests/labs that are ordered and lab results
 Diagnoses
 Therapies administered and medications provided or
prescribed
 Preventive services provided
 Disposition and patient instructions
 Provider’s name and title
 Length of the visit (e.g., minutes required to document
time-specific procedures)
Minimum Records Processes
 Develop and implement a process
addressing the use of standard forms
including
 Responsible parties for form development
and revision
 Form approval process
 Definition of timeframe for periodic review
and revisions of forms
 Consistent use of forms across sites
CMS/AMA General Principles of Record Documentation
 An individual record is established for each person
receiving care
 The patient’s name should appear on every page with
their unique identifier (patient record number)
 The record should be complete and legible
 Documentation of each encounter should include
 Reason for the encounter
 Relevant history and physical examination
findings
 Prior diagnostic test results
 Assessment, clinical impression, or diagnosis
 Care plan
 Date and legible identity of the observer
CMS/AMA General Principles of Record Documentation
 If not documented, the rationale for ordering diagnostic
and other ancillary services should be easily inferred
 Past and present diagnoses should be accessible to
the treating and/or consulting physician
 Appropriate health risk factors should be identified
 The patient’s progress, response to, and changes in
treatment and diagnosis should be documented
 The CPT and ICD-9-CM codes reported on the health
insurance claim form or billing statement should be
supported by the documentation in the medical record
 If it’s not legible, it’s not there
 If it’s not there, it wasn’t done
Universal Record Standards
 All clinical information pertaining to a
patient is kept in the record and must be
readily available any time the facility is open
 Multiple sites
 Filing systems
 Records elsewhere – radiology,
counseling, etc.
 Standards apply across all settings and are
compiled from JCAHO, NCQA, AAAHC,
Medicare, and Medicaid
Universal Record Standards
 Information should be recorded by the provider at
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the time of care
 At least on the same day
 The longer the delay, the lower the quality of the
entry
All staff should use the same set of approved
abbreviations and symbols
All entries must be dated, timed, chronological,
legible, and signed in non-erasable blue or black
ink by the provider with his/her credentials noted
after their name
 No blank spaces in between entries
Corrections can only be made with a new entrycross out and initial
Reimbursement and Records
 Physicians and mid-level providers can make
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entries in the record and may generate
charges during a patient visit
All payers have specific guidelines about how
to submit claims for non-physician charges
 Some payers may credential non-physicians to
allow charges to be submitted under their own
provider number
 Others only allow billing under a physician
 Whatever the rules, be sure that your health
record documentation backs up the billing
Reimbursement and Records
 Charges can be generated based on office
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visits, consultations, procedures, diagnostic
tests, X-rays, injections, vaccinations, and/or
supplies
Supporting documentation (including who
provided the service) has to be located in the
progress notes, laboratory reports, X-ray
reports, or diagnostic service reports
If services are provided in multiple sites (e.g.,
exam room and lab), charges have to be
collected and organized for billing purposes
 A data collection form is the best way to do this
Why set-up record policies and procedures?
 Maintaining record policies and
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procedures is essential to
protect your program and
patients
Licensing and accrediting
bodies, as well as governmental
entities, require them
Your policies and procedures
dictate how health information
will be maintained and protected
Your policies set the basis for
your legal record
Minimum Record Policy Elements
Confidentiality policies and procedures
Chart organization: sections, forms, and their order in
the chart
 Including specifications of what constitutes a
complete record
Record maintenance, storage, retrieval: access to
and archiving, backing up, security, and destruction
Patient compliance: informed consent and
authorization to release information
Health record documentation practices: who, how
and when; entry authentication; correcting the record
Sanctions or progressive discipline policy for staff
who do not make proper entries into records
Set Your Record Audit Policy
 Internal record audits should be performed as part of
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your program’s QA procedures
 Internal review allows problems to be identified and
corrected before someone else does it for you
Record internal audit policies should address
 Audit content
 Auditors
 Audit timeframes, breadth, and scope
 Levels of review
 Audit types
 Qualitative or quantitative deficiency analysis
 Detailed audit process
Records Policy Implementation
 When policies are developed, be sure
 Input on the content has been
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received from all levels of staff, as
appropriate
Staff are trained on the content and
retrained annually
 Maintain training session
attendance records
All new employees should be
oriented upon hire
All staff training should be
documented
Staff should have easy access to
relevant policies
 Computer access is ideal
Step-by-Step
Billing Process
Billing Process
Schedule
Appointment
Generate & Sign Bill
Register/
Determine Eligibility
Submit Bill
Contact Payer
No
Verify/Auth
Payment?
Yes
No
Pend/Denial?
Yes
Provide Care
Deposit
Correct
Coding
Post Payment
Re-submit
Charge Entry
Bill Patient
if applicable
Components of Bill Generation
 Schedule appointment
 Collect as much patient information as possible
 On-site registration
 Collect and verify outstanding patient demographic
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and insurance information
 Conduct financial screening, as necessary
 Create or have patient health record available
 Generate encounter form
Provider encounter form
 Provider completes encounter form and health
record, both of which go to coding
Components of Bill Generation
 Coding a claim
 Coder verifies record notes, assigns appropriate
codes, completes encounter form, and forwards
it to billing department
 Generating a bill
 Billing department books appropriate service
charge and produces bill based on completed
encounter form
 Submitting a claim
 Bills are aggregated to form a claim, claim is
attached to transmittal sheet identifying included
bills, and both are submitted to third party payer
Common Billing Forms
 The CMS1500 is the standard form used to bill
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all third party payers for professional services
 It must be completed accurately
 Timely collection of third party
reimbursement depends on this form
The CMS1450 (UB-92) is the billing form used
for hospital-based outpatient care
CMS1500 – Top of Form
CMS1500 – Bottom of Form
Code Sets
 Coding transforms descriptions of diseases, injuries,
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conditions, and procedures from words to
alphanumerical designations
The purpose of coding is to utilize code sets (ICD-9CM, CDT, CPT, DSM, HCPCS, DSM) to classify patient
encounters
The actual code set used is determined by
 Healthcare setting
 Regulatory agency
 Reimbursement system
 Approved HIPAA transaction code sets
ICD-9-CM, HCPCS and CPT are the primary coding
systems that are used to determine reimbursement in
the United States and selected under HIPAA
International Classification of Diseases (ICD)
 ICD-9-CM has two volumes of diagnosis codes
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and one volume of procedure codes
Resources for ICD
 Coding Clinic is a newsletter containing coding
advice
 It is published quarterly and helps you keep up to
date with ICD-9-CM
 Coding Clinic is agreed upon by a wide variety of
parties and is considered authoritative
 Call 1-800-261-6246 to subscribe
Sample ICD-9-CM Codes
Current Procedural Terminology (CPT)
 Owned by the AMA and designed to facilitate
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communications between physicians, mid-level
practitioners, and third party payers
Codes represent procedures and services performed
by clinicians and some codes for other staff
Contains evaluation and management (E/M) codes
To help with CPT coding, the AMA publishes a
monthly newsletter called CPT Assistant
 Call 1-800-621-8335 for subscription, or go to
http://www.ama-assn.org/catalog
CMS, Medicare carriers, and fiscal intermediaries
publish transmittals and bulletins about CPT coding
to guide you in their use
Sample CPT Codes
Healthcare Current Procedural Coding System
(HCPCS)
 HCPCS Level II Codes represent supplies, materials,
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injectable medications, DME, and services
Used mostly for ambulatory care and is a three level
system
 Level I is the CPT code
 Level II codes are developed and maintained by CMS and
updated quarterly
 They are used primarily for reporting purposes in
ambulatory care claims processing
 Level III codes are for new procedures, devices, and services
not in Levels I and II
 Defined by fiscal intermediaries and vary by location or
payer
 HCPCS – useful information at www.cms.gov
Sample HCPCS Codes
Other HIPAA Standard Code Sets
 Code on Dental Procedures and Nomenclature, Second
Edition (CDT-2)
 Developed and maintained by the American Dental Association
to record dental procedures
 Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM IV)
 Developed and maintained by the American Psychiatric
Association to code diagnoses made by mental health and
substance abuse treatment providers
 National Drug Codes (NDCs)
 Developed and maintained by the Food and Drug
Administration to report prescription drugs in pharmacy
transactions and some claims by health claim professionals
Coding Process
 The process of who does the coding may vary among
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settings
 However, the function of assigning codes does not
change
Providers and coders take clinical information (e.g.,
diagnostic terms, procedure descriptions) and assign
a code to each one according to official rules
Coders would take this clinical information from the
provider’s portion of the health record
 The provider is responsible to record proper
information
Coding professionals do not make assumptions or
use personal preferences
 Coding guidelines absolutely prohibit this
Coding Tips
 Documentation must substantiate the bill
 The note should back up the code chosen, and
vice versa, or you can lose reimbursement
 Coding is a joint effort between the clinician and
coder to achieve complete and accurate
documentation, code assignment, and diagnostic
and procedural coding
 ICD codes labeled “not elsewhere classified (NEC)”
or “not otherwise specified (NOS)” should be used
only when the documentation in the record does not
provide adequate information to assign a more
specific code
More Coding Tips
 Code to the highest level of specificity when applying
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codes (i.e., use the 4th or 5th digit if they exist)
Do not code diagnoses documented as “probable,”
“suspected,” or “rule out” as if the diagnosis is
established
 Guidelines for these were developed for inpatient
reporting and do not apply to outpatients
 You have to code the symptoms, signs, abnormal
test results, or other reason for visit if no
diagnosis is established at that time
 When no definite condition or problem is
documented at the conclusion of a patient care
visit, the coder should select the documented
chief complaint or symptom
Evaluation and Management (E/M) Coding
 All physicians, regardless of specialty, may use any
E/M service code
 History, examination, and medical decision-making
are the key elements when determining a level of
service
 There are different codes for new and established
patients
 E/M codes encompass wide variations in skill,
effort, time, responsibility, and medical knowledge
required for diagnosis and treatment
 Includes private/clinic “office” visits or hospitalbased outpatient visits and other types of services
provided by physicians and mid-level providers
Coding and Reimbursement
 Coding errors can result in delayed, incorrect, or no
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payment
With the added scrutiny of the Office of Inspector
General and others, it is increasingly more
important to minimize errors that can result from
incomplete documentation or inappropriate use of
codes
Patient records have to include documentation for
medical care, diagnostic tests, procedures and all
other services submitted for payment
Coding Audit Triggers
On Medicare’s Current Hit List
 Excessive use of higher-level E/M codes—too much
use of 99215
 Billing for consultations on established patients for
minor diagnoses that do not support this level of
service
 Billing for excessive repetition of lab tests when
results are typically normal for that patient
 Upcoding and overutilization billing for office visits,
especially when services were not medically
necessary
TPR
Collections:
Step-by-Step
Billing Process
Schedule
Appointment
Generate & Sign Bill
Register/
Determine Eligibility
Submit Bill
Verify/Auth
Payment?
Contact Payer
No
Yes
No
Pend/Denial?
Yes
Provide Care
Deposit
Correct
Coding
Post Payment
Re-submit
Charge Entry
Bill Patient
if applicable
Collecting Third Party Payments
 Remittance Advice (RA)
 Third party payer forwards a RA to billing
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provider
 RA is usually accompanied by an Explanation
of Benefits (EOB) form and a check for paid
bills
Deposit payment – deposit payment
immediately upon receipt
Post payment – payments made on outstanding
amounts should be posted to patient accounts
Collecting Third Party Payments
 Bill secondary payer
 As appropriate, bill secondary payer (s) for
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remaining patient balances (or coordination
of benefits)
Bill patient
 After payment from a secondary payer is
received, bill patient accordingly
Analyze pended and denied bills
 Analyze RAs and EOBs to identify and
resolve correctable billing errors
Resubmit corrected bills
Remittance Advice (RA)
 The RA, or remittance statement (RS), is a written
notice from a third party payer
 Itemizes submitted bills
 Identifies the payment amount for each submitted bill
 Gives the payment status of each bill (paid, pending, or denied)
 For each bill, the RA also shows
 Provider’s name and number
 Date of service
 Patient name and insurance ID number
 Service description, coding and billed charge
 Amount paid or payable for billed service (s)
 Patient deductibles or co-pays
 Payment status
Remittance Advice (RA)
Explanation of Benefits (EOB)
 Provider and patient identification
 Dates of service, procedures, and charges
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submitted
Disallowed charges and explanation (usually codes)
Allowed charges and explanation (usually codes)
Deductible (if applicable) and year to date total
Co-pay, if any
Amount payable by the payer
Identifies incorrect billing information that can be
perfected and resubmitted
Highlights ineffective operating procedures for
collecting patient and service data used in billing so
they can be modified, as needed
Identifies the need for staff training on data
collection and billing
Explanation of Benefits (EOB)
EXPLANATION OF BENEFITS (EOB)
Green Cross Health Plan
P.O. Box 123
Anywhere, US 54321
Reference
Number
205914240
204397307
Check
Number
8283093
3491794
Member Number: D481605-01
Member Name: John Q. Public
Provider
Number
Provider
Name
217617 M. Welby, MD
217617 M. Welby, MD
Dates of Service
From
To
2/1/02
2/1/02
2/1/02
2/1/02
Service
Code
Service
Description
99203 Office Visit - New Patient
93000 EKG
TOTALS
Requested
Charges
Allowed
Charges
Plan
Liability
Patient
Liability
$80.00
$110.00
$70.00
$80.00
$60.00
$80.00
$10.00
$190.00
$150.00
$140.00
$10.00
EXPLANATION CODES:
40 – Denial decision has been overturned. This claim is being paid according to the member’s benefit plan.
838 – Patient is responsible for payment of $10.00 copay to provider.
THIS IS NOT A BILL. PLEASE SAVE THIS COPY FOR YOUR RECORDS.
Explanation
Code
838
40
Bill Tracking and Adjustment Activities
 Essential bill tracking and adjustment functions
 Provider productivity
 Analysis of coding
 Frequency of illnesses
 Frequency of chronic versus acute illness
 Analysis of cost of care
 Account aging
 Cost center income and expense
 Profit and loss (yes, even in not-for-profits)
 Status of reimbursement transmittals/claims
 Bill tracking and adjustment activities are essential to
maintain adequate cash flow
 Adding computerized tools can help with tracking and
management, thereby improving cash flow
Overview of the Claims Payment Process
Reject Claim
No
Patient ID
Match?
Calculate Allowed
Charges
Yes
Reject Claim
No
Procedure(s)
Covered?
Calculate Deductible
(if applicable)
Yes
Reject Claim
No
Procedure(s)
Match Diagnosis?
Calculate Copay (if
applicable)
Yes
Reject Claim
Yes
Duplicate
Claim?
Create EOB
No
Reject Claim
Yes
Other Payer
Responsible?
No
Send EOB and
payment
Overview of the Claims Payment Process
1. Payer scans the claim for a match with their
database
2. Claim procedure codes are checked
3. Procedure codes are compared to claim diagnosis
codes to confirm medical necessity
4. Claim checked against previous claims
5. Claim is checked to determine if another payer has
responsibility to pay
6. Allowed charges are calculated
7. Deductible, if any, is calculated
8. Co-pay, if any, is calculated
9. EOB form is created
10. EOB and payment is sent to provider
Rejected Bills
 Payable bills can be rejected due to correctible errors
 It is important to track rejected bills to
 Identify improvements in billing and collection
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processes
 Highlight correctable program operations and
billing problems
 Assess performance of billing staff
 Get additional revenue
Some bills are rejected because they are un-payable
 Other bills are rejected because the claim was
completed incorrectly or contained incorrect data
Electronic bill submission, either internally or through
an outside firm, can reduce rejections and expedite
payment
Common Reasons for Rejected Bills
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The patient not on file
The bill is for non-covered services
The procedure not medically necessary
Out-of-network provider (rejected or
reduced payment)
A required preauthorization was not
secured
The patient’s coverage was terminated
prior to date of service
Other payer responsible
Automation
To Computerize or Not
 HIPAA requires electronic claims submission
 Billing and collections effectively require on-going
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management
It is advisable, although not necessary, for a very
small operation to computerize the data you need to
collect
 General benchmark
 < 10,000 visits annually = manual system
 > 10,000 visits annually = computerized system
Billing software vary in cost and training requirements
 Look before you leap
Building Your
TPR Team: Tips
in Reviewing
Your Staff
Responsibilities
Staff Responsibilities: Registration Clerk
 Constructs patient health records before visits
 Has records available when patients arrive
 Ensures patients arrive at your program and “sign in”
 Registers arrival time
 Ascertains if insurance status or address have changed
 Ensures patient demographic data is correct
 Handles appointment reminders by calling patients or preparing
reminder cards
 Clerk may
 Record the patient’s chief complaint
 Complete forms in the health record with demographic data
 Explain co-payment or deductible to patient and collect the
cash or charge to credit card
 Transcribe codes to face sheet or a super-bill based on the
patient’s chief complaint (if trained by your coder)
Staff Responsibilities: Coding Staff
 Encounter forms typically allow providers to check off item(s) on
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the forms that list many visit/procedure options and diagnoses,
with the corresponding codes
The medical visit level and diagnoses and procedures are taken
from the encounter form, coded, and entered into a billing system
 Coders should ensure corresponding notes are in the record
If coding notes, obtain health records, encounter form(s), or
charge slip(s) and determine codes
Enter codes into billing system if they assigned the code,
otherwise this is a biller’s function
If coding staff are not entering information directly in a computer
program, a manual log sheet can be used
Verify accuracy of date and place of service
If billing software is available to execute claims, coders and then
billers initiate the billing process
Physical layout is important for coders to be able to be most
effective, they need to concentrate
Staff Responsibilities: Billing Staff
 Charges or fees are then applied by the biller
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and CMS1500 claim forms are generated
Verifies that all services provided were coded
 Matches encounter slips to appointment
register
Enters charges for services and generates
bills
Completes claim transmission and submits
claim in a timely manner
In small organizations the biller and coder can
be one person
Staff Responsibilities: Accounts Receivable (AR) Staff
 Posts, or records, the payments received from the payer
 Reviews Remittance Advice for
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Inaccurate information
Adjustments
Pended bills
Denials
Examines the EOBs to identify reasons for payment delays
 Communicates each reason to the provider, coder, or biller, as
appropriate
If payment is banked by electronic fund transfer, this reduces
days in AR
 AR staff should know the date these deposits should be made
and ensures the transactions occur
Claims should all be paid within specific time limits
 AR staff should track or project payment dates and analyze
this information to identify slow payers
Provide input into fee schedule changes
Staff Responsibilities: Finance Staff
 Oversees all financial transactions, including
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billing, coding and collections
Posts cash to the accounting system
Produces cash flow reports, including aged
AR, days in AR, and dollars in AR
Regularly reports performance to CEO and
board of directors
Periodically audits coding and billing
practices and ensures staff compliance with
appropriate internal controls
Reimbursement
Infrastructure
Constructing a Billing Department
 Well-trained intake/registration,
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coding, billing and collections
staff, as well as adherent
providers, are essential for
success
It is important to remember billing
begins with the first contact by the
patient
 This is their point of entry into
service
Consider billing process and
functionality when making staffing
decisions
Constructing a Billing Department
For those of you who do not currently bill
 To decide on a plan to go forward
 Analyze who currently handles
 Scheduling
 Intake and registration
 Eligibility verification
 Creation of records
 These staff members can work collaboratively
to create an effective billing department which
integrates front desk, coding, billing, and
claims submission functions
Re-engineering a Billing Department
For those of you who currently bill
 It is a good time to get the entire front and back
office together and go over all of your
functions
 Ensure everyone is on board with the philosophy
that you need to be paid for what you do, and their
connection to the payment cycle
 Review everyone’s functions while together to
ensure that everyone understands the jobs that
others do
 Be sure everyone understands they are an essential
piece of an important process
 Cross-train everyone, plan for vacancies and
vacation
Constructing a Billing Department
 Before you meet with all staff, review financial and



demographic data that are currently collected to
identify information gaps in your data
If currently billing
 Pick one important issue/problem, and teach
people how to flowchart the current process
 Then, together, develop one ideal process
For those not currently billing
 Develop flowcharts documenting optimal patient
flow processes and supporting administrative
functions
 Design a physical office layout around the optimal
Create tracking tools to ensure same problems do
not recur
Billing and Collections Processes Implementation
 For agencies newly billing
 Now you are ready to conduct a simulation of


the entire billing process from patient
registration to payment posting and refine, as
necessary
For agencies currently billing
 Be sure to pilot your solutions first, and then
implement them on a full scale
 Work out the bugs
If your program does not have a provider number
(s) and/or claims transmission authorizations,
apply for these now
 Test transmission capability before submitting
the first “real” claim
Qualified Coding Staff
 Coding professionals are trained and often certified
 Beginning coders’ skills and credentials are

adequate for primary care or freestanding
outpatient settings
Two organizations award coding credentials
 American Health Information Management
Association (AHIMA)
 American Academy of Professional Coders (AAPC)
 Both have national credentialing exams
How do we estimate our financial return from TPR
billing and collections?
 Three types of
information are essential
to estimate your return
 Patient base
 Services offered
 Service volume
What is your patient base?
 Identify prevalent insurers

for your patient population
 Learn their payment rates,
what services each plan
covers and under what
circumstances
Evaluate your patient
population to identify
uninsured clients versus
individuals eligible for
Medicaid, other public
programs, and commercial
insurers
What billable services does your HIV program offer?
 Insurers vary in covered

services, authorized providers,
and payment rates
Adjust your operations
accordingly
 Hire Nurse Practitioners (NP)
rather than RNs because NPs
are billable
 Case management may be a
covered service
 Charge for services that were
previously provided at no
charge
What is your service volume?
A shift in perspective may be required
 Fee-for-service reimbursement and all

inclusive rates are driven by the number of
encounters or services provided
Managed care capitated payments are
driven by the number of patients enrolled
with the provider
Alternative Billing Arrangements: Partnering
 Alternatives exist if the costs of

developing internal billing
infrastructure are prohibitive
Collaboration with complementary
organizations
 Buying into a common computer
system, with a firewall to protect
your organization’s autonomy and
information
 Share staff to access greater
expertise than you might afford on
your own
 Leveraging technical and financial
resources
Alternative Billing Arrangements: Outsourcing
Do we build or buy our own billing systems?
 Companies exist that can handle all of the
registration, billing, and collection processes by
providing experienced on-site staff
 Billing services can
 Speed up payments through efficient processes,
helping to improve cash flow
 Reduce rejected claims by catching billing errors
during front-end editing
 Stay current with any changes in payer billing
requirements
 Produce reports tracking billing performance
Staffing and Patient Flow
 Consider patient flow and your space needs and



construct your design layout accordingly
 Maximizing patient flow is the key
Processes to consider include
 Constructing charts
 Scheduling patients
 Verifying their insurance
 Collecting copays
 Handling walk-ins
 Telephone calls
 Making referrals
 Level of staff training on your software
Understand what your processes are, if they deter or
enhance patient flow, and aim for “no waits/no delays”
Map the entire process so that you can be sure that
staff can carry a task to completion
Staffing and Patient Flow
 Cross-trained staff should know when to jump in and help

and be trained in troubleshooting
To start your process mapping, gather some information
 Number of incoming and outgoing calls per day
 Number of visits per day/total and totals by type
 How many individual people call in by type -patients/







referrals/ pharmacies, etc.
How many walk-ins per day - patients and others (sales
people)
Number of other interruptions, e.g., audits, deliveries
Frequency of diagnoses (severity of illness)
Service volumes, e.g., number of blood draws per day
Number of new versus established patients seen per day
Vacancy rates/absentee rates for all staff
Number of charts constructed per day
Billing and Collection Processes Implementation
 Train all of your staff, including providers
 All policies and procedures relating to coding,




billing, health and other record management and
accounting
 Federal/state and local regulations and new
regulations, as they evolve
 Corporate compliance
 HIPAA requirements, general fraud and abuse
issues
Documentation
Confidentiality and security
Coding requirements, such as E/M code rules and
prohibitions on up-coding/double billing
Third party payer expectation
Implementation: Staff Education
 All staff need education
 Concentrate on provider and front office staff






concurrently
Keep providers coming by making training topical and
relevant to what they do on a daily basis
Keep training limited to 30 minutes per session
Provide follow-up to training by documenting results
of what was learned
ALWAYS follow policies and procedures as written
 If you do not, then revise the policies
Motivate staff to come to training
Reinforce the consequences of inadequate
documentation
Other TPR Modules on Website
Visit www.positiveoutcomes.net for
additional training modules
 Automation of Records and Billing
Functions
 In-depth Coding and
Documentation Practices
 In-depth Billing and Collections
Management
 Corporate Compliance
 Credentialing
 HIPAA