Most healthcare organizations partner with physician services groups for niche coverage. While outsourced medical services are available across all specialties, common areas for external physician support include anesthesia, radiology, wound care, and emergency medicine. However, when outsourced physician services are used, challenges to ensure accurate reimbursement for both components of care—the hospital portion and the physician’s professional fee—increase.
Snafus are largely attributable to information gaps between three primary parties involved: outsourced physician services groups contracted billing companies and health system revenue cycle teams. Communication and information technology (IT) handshakes between these stakeholders are often fraught with data disconnects, leading to cumbersome billing and coding workflows across the board. The professional fee revenue cycle gets caught in the crosshairs.
Here are seven best practices to ensure proper reimbursement for the professional fee component of healthcare’s revenue cycle using emergency department (ED) services as an example.
Emergency medicine is at the center of a not-so-perfect storm on the reimbursement front. Medical service providers, emergency medicine physician groups and hospital EDs are under intense pressure in four specific areas:
– Volumes and costs are on the rise: Rural emergency department visits have jumped more than 50 percent in the past decade and the average cost of a hospital ED visit jumped 135 percent since 2008.
– Congress is looking to outlaw surprise ED bills: One in five emergency room visits results in a surprise bill and 19 percent of all surprise, out-of-network bills are for ED services.
– Patients are becoming primary payer in the ED: Even patients covered by employer-sponsored insurance plans struggle to pay their ED bills.
– Health plans and government payers cut back coverage: Both parties announced more rigorous requirements for ED claims in 2018 for specific diagnosis, procedures, and treatments.
It is essential for all involved in the ED revenue cycle – emergency medicine practices, emergency billing companies and health system executives – to maintain a high level of revenue integrity amidst a storm of financial risk. New levels of cooperation between emergency medicine groups, billing partners and the hospital revenue cycle are also required to eliminate inefficiencies and ensure proper payment.
Here are seven best practices to manage professional fee coding in emergency medicine to achieve better financial performance:
Guarantee Prompt and Accurate Data Transfers
Emergency practices ideally receive ADT demographic data from hospitals via an HL7 message. In a perfect world, the information is then passed to insurance verification partners to run up-front demographic and insurance checks with full integration back into the practice’s billing system. But demographics and insurance data are only the first step.
Emergency groups and billing companies also need clinical documentation, reports, chart addendums and other ED notes gathered during the emergency encounter to ensure accurate coding, expedite the billing process and pass along clean claims to the payor.
All of these components are essential to support a healthy ED revenue cycle for both professional fee and the hospital component. In a large outsourced physician services group, secure data connections across dozens of EHRs, EMRs and emergency practice billing systems are extremely challenging to secure.
Tip: Spend the extra time and dedicate IT resources to establish proper data transfers.
Evaluate Self-Pay Upfront
Dealing with self-pay patients brings about a new set of challenges, especially with the numerous laws and regulations surrounding emergency medicine. Furthermore, ED claims are frequently “first in” to the claims process, thereby falling within the patient’s deductible. Patients as the primary payer is a common scenario in emergency care.
Emergency groups should take proactive steps with self-pay patients. Every attempt should be made to conduct prompt financial assessments and uncover billable insurance. Converting a self-pay patient to billable insurance coverage can mean the difference between a smooth billing experience and a protracted self-pay collection process.
Tip: Be proactive with self-pay patients, including patients with high deductible health plans.
Determining the patient’s propensity to pay any remaining balances should be the top priority. If the patient’s ability to pay is determined early on, billers and collectors can segment accounts and assign their focus accordingly. This practice decreases the amount of accounts staff need to manage. It also reduces the number of accounts sent to a collection agency, effectively streamlining their work.
Integrated, on-demand payability scoring services eliminate lists, batches, website searches, and waiting for results. Understanding the likelihood to pay also prioritizes how much time everyone spends trying to code, bill and collect emergency encounters.
Tip: Conduct payability scoring and segment accounts accordingly.
Boost Coder Productivity
According to a recent Health Affairs survey, doctors spend about three hours per week on billing-related matters, including clinical coding. And for every 10 physicians providing care, almost seven additional people work on billing-related work. For emergency practices or billing companies dealing with these challenges, decreasing time and cost through boosted coder productivity should be a strategic goal.
Advanced coding technology ensures that all steps are accurately and thoroughly completed. One move would be to bring all documents needed for coding together into one coding platform, using special work queues for deficiencies, discrepancies, unbillable cases or those requiring additional validations. Also, be sure to communicate with physicians for missing documentation, address coding audits and check compliance all within the single coding workflow. Measure productivity as an automatic by-product of the coding process.
Tip: Find ways to save time and money in the coding process and consider advancing your coding technology platform.
Protect the Revenue You Earn
Physicians, coders, and billers should also know specific codes that should never be included in ED claims. Correct use of modifiers, coder education, and physician documentation training are all essential components for decreasing claim rejections and payer denials.
To optimize revenue earnings, cite a high-quality differential diagnosis that justifies the medical decision-making and the patient’s severity whenever possible. Be specific with the final impression and avoid unspecified codes, which is sometimes difficult to do in emergency care.
Tip: Comply with national, uniform guidelines for coding ED visits.
Report Bad Payer Behavior
With systematic practices of unfair payment for emergency services, it is advisable to challenge or appeal unfair denials to the Emergency Department Practice Management Association (EDPMA) Quality, Coding, and Documentation Committee and the American College of Emergency Physicians (ACEP) Coding and Nomenclature Advisory Committee. A concerted effort among providers is needed nationwide to curb the enthusiasm of overzealous payers trying to trim costs and minimize provider reimbursements.
Tip: Be proactive and aware of payer coverage changes, know payers’ discretionary policies that limit certain conditions covered in the ED, and educate revenue cycle teams accordingly.
It is important to collate data from multiple sources, including who was seen, their demographics and insurance information, and the charges chosen by providers. In additional to centralizing this information for emergency encounters, also check and verify the physician documentation. Determine what’s missing before the case is submitted to the coding queue, including which providers are missing notes, which cases are on hold for other data and reconciliation of cases. Finally, when documentation gaps are noted, report and notify providers via a coding query or other form of automated communication.
Tip: Collect data from all necessary sources and collate into a single workflow, including the ability for revenue cycle staff to query physicians for missing information or documentation.
Optimize Revenue Cycle Workflow For Emergency Encounters
ED accounts are managed more effectively by taking fewer and more logical steps. Addressing the rise in higher deductibles requires a shift in revenue cycle management strategies and tactics. Try the seven tactics mentioned above to address the rising level of complexity required to successfully manage ED claims and ensure accurate professional fee reimbursement.