“Mars-landing” capabilities urgently needed in denial management

Jesse FordRevenue Management

Last month I watched in amazement as NASA’s Perseverance Rover touched down softly on Mars. After traveling six and a half months and over 100 million miles, Perseverance aimed for the Jezero Crater, a 5-by-4-mile area featuring dangerous pits, cliffs and boulders. As I watched, I marveled at the precision of each calculated step that led to touchdown, and I celebrated (not always knowing why) whenever the NASA team cheered. NASA prepared for years and applied innovative, automated technology that mapped and analyzed rough terrain to find a precise spot for a flawless landing.

Being a technology geek as well as someone who spends his time thinking about how to streamline revenue cycle workflow and processes, naturally I started to think about denial management. OK, it’s not the Mars landing, but it is a complex topic, made mission critical by the unprecedented strain on cash flow at healthcare entities across the nation.
The new technologies that allowed NASA to hit its target to perfection were not available for the early efforts at landing rovers or stationary devices, a few of which crash-landed. In healthcare revenue cycle today, our applications and processes are closer to NASA’s older technology. We need to advance denial management into “Mars-landing denial science.”

Hitting the wrong spot
Traditional denial management depends on data from remittance advice and other sources, and the denials are typically mapped to categories to identify trends. With this data, and in the spirit of “collaboration throughout the revenue cycle,” denials are assignedto the department that caused them, such as health
information management, utilization review, clinical service areas and registration. These departments are responsible for investigating the root cause of the denial and implementing improvements to ensure future claims won’t meet the same fate.

What if Perseverance landed on Mars, but missed the Jezero Crater? NASA selected this spot following five years’ research because Jezero offered the most promise for uncovering whether Mars held life billions of years ago. Missing it by a small margin would have ruined the mission. The problem with traditional denial management is that it frequently lands in the wrong spot – in areas that did not cause the denial and/or in the wrong follow-up work queue. The fault lies in problematic data.

The data problem
Denial data is inconsistent and potentially misleading. Under HIPAA, the government established national standards for electronic transactions, including codes that explain denials. However, between codes changing periodically and payers interpreting them differently, we’ve found that the categorization is not simple and cannot be static. In a 90-day period for one of our clients, a reason for denial based on “non-covered service” included eligibility (50%), coding or coverage (45%) and insurance and other issues (5%).

Based upon our client data, payer inconsistency could affect from 10% to 30% of denials that healthcare providers receive. NASA would not be satisfied with anything like that kind of failure rate. When data are faulty, denial management teams make inaccurate assignments and conclusions, including holding the wrong departments accountable.

Denial science
The industry is ready for denial scientists and next-generation technology embedded in the business office.
Denial scientists apply scientific method to identify and correct data anomalies. Scientific method consists of making observations, formulating hypotheses, testing hypotheses, drawing conclusions and refining hypotheses. It implies that there is potential to continuously evolve as new hypotheses lead to new conclusions.

As a simple example, consider seeing a large volume of denials related to revenue codes. In health systems, there is typically a manager responsible for the charge description master (CDM) to map revenue codes to each service provided. In traditional denial management, the revenue code denials would be automatically routed to the CDM manager to fix issues. However, in this case the denial scientists identify that only one insurance is sending this denial. It is rare for revenue codes to be mapped differently for each payer, so the hypothesis is that this was not a CDM manager issue. Investigation reveals this was a false denial from the insurance company.

In a much broader context, an approach utilizing denial scientists to investigate denial abnormalities ensures accurate data and enables departments to review clearly defined problems, potentially saving their work on 10% to 30% of accounts. The time saved translates to more time to focus on improving processes or, more importantly, on patients.
Artificial intelligence will likely be the future of denial management. I have noted previously that right now AI is more of a dream than a reality in revenue cycle, however much the term is bandied about. In the meantime, we need real-world solutions that:

  • Enhance the accuracy of reporting denials and denial trends
  • Accurately assign denials to responsible departments so they can identify and correct the root causes
  • Simplify/optimize denial workflow and training

A focus on data integrity through denial science can ensure these goals are achieved and denial improvement objectives land precisely where they should, like Perseverance.

In today’s healthcare revenue reality, such an outcome, however far from the headlines, would be something to cheer.

The math behind turning bad debt into cash collections

Richard DeSoto, CRCERevenue Management

Editor’s note: This article first appeared in the winter 2021 issue of AAHAM’s Journal of Healthcare Administrative Management.

During this long pandemic, revenue cycle management has had the daunting task of improving cash flow with fewer internal resources, amid a shift to remote work. Many organizations, faced with demand for quick change, have outsourced some or all of their business offices, hoping for the best.

As 2021 dawns, some organizations seem to have righted the ship, but as the virus rages, most continue to struggle and are having difficulty seeing a path forward. Some have established processes in the form of requests for proposals that spell out their needs, while others are calling vendors they have worked with before, with a plea that can be summarized in a single word: Help!

I have two questions for anyone thinking of outsourcing:

  • Is additional support needed immediately to improve cash flow and operational requirements?
  • Do you have an established baseline of reporting data to determine your goals for improvement (ROI)?

My past experience working with hundreds of hospitals, providers and health systems tells me that all have some key performance indicator data that they can use as a baseline to establish performance goals and decide whether to seek outside help with revenue cycle operations.

Let’s evaluate the numbers for a large, multi-hospital, safety-net health system that uses multiple vendors throughout the revenue cycle operation, from eligibility processing in registration to bad debt. At this system, the vendors seem to be performing well, according to recent year-end financial reports. Taking a harder look at the data, though, reveals some performance gaps and missed opportunities for improvement.

Annual gross patient revenue for the system was approximately $5.6 billion. After taking out the allowance for doubtful accounts, charity and contractual adjustments, net patient revenue was approximately $1.25 billion. That’s certainly a bunch of money and an improvement on fiscal year 2019 results, but it still only represents 22.5% of gross (charged) revenue. When dealing with large organizations producing large numbers, even the slightest improvement or decline can also produce large numbers and variances. As an example, if we were to assume that net patient revenue equates to payments made to accounts receivable, a 1.5% improvement to the system’s payment activity would be almost $19 million in additional cash, which could be freed to use on operations. Asking revenue cycle staff to improve cash by 1.5% seems reasonable.

Marginal change, better margins
Now let’s dig a little deeper, taking a look at collections and bad debt. The system is showing approximately $650 million in bad debt. As accounts are generally written off net of contractual allowance, this seems to be a net number. Assuming the revenue cycle leaders can get their early out vendor and internal staff to improve collections by just 1.5%, bad debt goes down and the cash position rises by almost $13 million.

So how do you make this happen?
I recommend that you start off with some baseline information. What are the total self-pay collections for last fiscal year? Can you break down these collections by straight self-pay and self-pay after insurance? Can you report self-pay after insurance by payer classification? What are the revenues by payer classification? All this information can be very helpful in evaluating where to improve processes and reduce bad debt.

It appears the system is attempting to collect self-pay as early as possible. It has implemented point of service collections at all entry points and is tracking those payments. Results vary, but progress is being made. The system has a robust insurance verification tool and service estimator to provide the patient with self-pay expectations prior to service. The system has partnered with an early out vendor that receives accounts at 31 days after service for straight self-pay. For those with some coverage, the vendor sees the account 31 days after insurance payment is received and insurance balances are zero and/or moved to self-pay after insurance. Patients receive timely statements, some collection call attempts are made, and some large balance accounts are screened for Medicaid eligibility or charity-care status. It’s the policy of the system to send an initial detail type bill for outpatient accounts and a summary uniform bill for inpatient accounts. After three statements the patient receives a final demand notice. It is at this point that the patient financial services system produces a pre-bad-debt List.

When business as usual blunts opportunity
Typically, most revenue cycle operations have some type of pre-bad-debt report that has a list of accounts that if not paid within a set period (usually one to four weeks), accounts will automatically move from active accounts receivable to placement with a bad debt agency. It is the responsibility of staff to review and make one last attempt to collect these unpaid accounts before writing them off their active accounts receivable and placing them with an agency. In practice, it is my experience that most organizations do not actually review this list. They simply acknowledge that the final statement requesting payment has been made, the account sits unpaid for the required time, and then it is transferred to the collection agency.

As noted above, establishing a baseline to determine effectiveness of the early out vendors and others involved in the collection of accounts receivable is critical. One method is to take the total self-pay payments and divide that amount by the self-pay placements. This is a very simple and effective KPI, but it has one caveat to keep in mind: Most collection efforts get rolling as long as a month after an account is placed, but large placements made within the last 15 days will lower your collection percentage.

As it is, our health system with $650 million in annual bad debt is writing off almost 12% of total revenue. As a safety net hospital serving a large metropolitan area this may not be too unusual. Of that total, how much is being collected by bad-debt agencies? I suspect very little, but for now this is just an unknown number that should be baselined.

Comparing payments to placements (less provider request for return with no action) brings us to another measurement: How much is being written-off to charity/financial assistance? In the case of this large system, approximately 4.3% of gross revenue. It appears from these numbers that bad debt is way too high and charity is way too low for this type of organization.

Two actions to consider
Take a more aggressive approach to identify potential charity. How much of the bad debt is made up of account balances greater than $5,000? Segment the balances to identify large balance accounts. Asking a patient to pay $100 is much easier to collect than asking for a payment of $100,000. The large balance should be worked more aggressively for Medicaid or charity. Although allocating more to charity does not increase cash, but it more accurately depicts how you are providing healthcare to the needy. By contrast, high bad debt represents a failure of your revenue cycle operation to collect receivables that could help deliver better care.

Another solution is to take on a vendor to work accounts and make a final collection effort for 15 to 30 days before assigning the account to bad debt. The vendor would need to be able to employ the latest technology. Using text, email and Interactive Voice Response (IVR) to reach 50% to 80% of this receivable will most certainly generate additional cash and reduce bad debt. The IVR should not be the standard “Press 1” for this or “Press 2” approach. Many patients do not respond well to automated systems like this. But what if this system could act like a real collector and have a conversation-like telephone call and response that would ask for payment and confirm the patient’s intentions to pay or not to pay? What if it accepted the patient’s response as is without making a tense situation worse?

This should be the goal of every revenue cycle operation – collecting self-pay receivables and improving customer service/satisfaction at the same time.

Documenting outpatient care requires even greater attention to quality

Jennifer SwindleCoding

Clinical documentation improvement (CDI) programs have become commonplace in inpatient care in the past decade due to continual flux in reimbursement rules and increased scrutiny of claims by third-party payers. With expanding volumes at outpatient facilities as a result of a shift away from higher-cost acute care, payers are using audits and other tools to ensure physicians in offices and clinics are accurately capturing services provided. Another factor driving the migration of CDI is that hospitals are acquiring physician practices, so they fall under acute-care CDI programs.

A major impetus for this new scrutiny is the Merit-based Incentive Payment System (MIPS), which rolled three quality and value reporting programs into one points-based program. MIPS isn’t just about scores and reputation, however; it is a catalyst to transforming physician practices from pay-for-volume to value-based reimbursement.

In any care setting today, physician participation, buy-in and support for CDI are crucial. Some physicians view this as just one of the many hoops they must jump through to get paid. They shouldn’t. Although there is an opportunity for a positive financial return, CDI is about quality. Accurate and complete clinical documentation will not only validate the care that was provided but also improve communication among all providers caring for a patient.

Any good CDI program incorporates factors such as severity of illness, risk of mortality, and length of stay. Lack of complete documentation may alter mortality and morbidity case mix index scores, which influence both physician and hospital profiles. However, outpatient CDI programs have distinct challenges from inpatient CDI. Outpatient visits are significantly shorter, making a concurrent review impossible. Also, the volume of outpatient visits is significantly higher. The program structure should allow for review as soon after the visit as possible, but prior to claim submission.

These factors result in much less medical information gathered from each episode to identify areas of opportunity. It also most likely will not be feasible to review all outpatient services, so the encounters most prone to risk should be identified.

Every organization will not have the same plan; each plan must be right for the types of outpatient care provided. Often when getting started a CDI program may focus on particular departments or service lines. Operational assessments may help determine where to focus efforts, paying special attention to claims denials at care sites with large medical necessity, such as the emergency department, observation services, ambulatory clinics, physician practices and ambulatory surgery centers.

Physicians are at the heart of all successful CDI programs, as it is their clinical documentation that is needed; however, clinical and coding language do not always translate directly. CDI programs help bridge that gap by helping to identify areas where things are not clearly stated so coding is done to a high degree of specificity.

There is some prospective work that can be done in an outpatient CDI program, including chart reviews of medication lists and chronic conditions, to update records and help plan what should be addressed at the time of the encounter, but the bulk of outpatient CDI is done after the patient encounter.

Objectives of inpatient and outpatient CDI programs differ, but quality of documentation is the driving factor. An inpatient CDI program often focuses on case mix index and severity of illness metrics while an outpatient program more often focuses on reducing denials and resolving missing charges.

You must have a way to measure results, so performance metrics are required. There need to be tracking tools and consistency in the data to allow key performance indicators to be established and met. The program should be incorporated into the normal workflow so as not to become a burden on staff and physicians. How physicians use and documentation in an electronic health record can have a tremendous impact on CDI. Staffing determinations may be resource-driven, input-driven or ratio-driven, but there needs to be a way to measure the return on investment. Timely feedback should be available.

In the end, the best metrics on documentation are whether care is improving and appropriate reimbursement for services rendered is being achieved.

RPM caution: Remote monitoring can boost care quality and revenue, but watch out for coding and documentation regs that may curb some enthusiasm

Jennifer SwindleCoding

Much attention has been paid to the explosion of telehealth technology and services during the pandemic. It is viewed as one of the bright spots in an otherwise bleak year in the business of healthcare. Mostly, the action has been in telehealth visits – doctors discussing care with patients over whatever communication devices they have, including phones. Most observers think an expansion of televisits is here to stay, but it is going to be more regulated post pandemic.

Another aspect of virtual care, remote patient monitoring (RPM), may turn out to have a more significant long-term impact on patient care and revenue than televisits. RPM, also called remote physiological monitoring, is the collection and/or analysis of data to help manage a treatment plan related to a chronic and/or acute health illness. It uses digital technologies to monitor, capture, and transmit vitals such as blood pressure, weight, heart rate, and blood sugar levels from patients to providers for assessment, recommendations and instructions.

Revenue enhancer
Thanks to an overhaul of CPT codes for 2020, RPM became one of the more lucrative Medicare care management programs even before the pandemic. The vast majority of RPM services are now billed under four CPT codes: 99453, 99454, 99457 and 99458. There is a small payment for initial patient enrollment into an RPM program, and then a monthly base payment for management of the device and patient readings. Finally, there is an optional service for each 20 minutes of care management – which can be provided by clinical staff – up to 60 minutes total. When added together, each RPM patient can earn a practice up to around $210 per month, according to McKinsey & Co. projections.

CMS has proposed further changes to these services for 2021, so when the current public health emergency ends, it is important to understand that you need to meet new coding requirements.
As with all services, medical necessity is crucial for coverage of RPM. It is also required that the provider obtain permission from the patient prior to providing RPM services; this patient consent must be documented in the medical record. The consent can be obtained on the same date as RPM services are provided.

The proposed rule for 2021 does clarify that RPM services can be provided to patients with acute conditions; chronic conditions are not required.

Who can provide RPM
Although the public health emergency waiver allows RPM for new patients, this will not be true once the emergency has ended, so only established patients can be monitored. RPM must be ordered and billed by the physician and/or other qualified healthcare professional (a provider with the ability to bill Evaluation & Management services, such as physician assistant, nurse practitioner, clinical nurse specialist; not ancillary staff).
There is some difference in what type of provider may furnish the service, as the 99091 can only be provided by the physician or other qualified healthcare professional; however, services for codes 99457-99458 can be provided by ancillary clinical staff as well, under the general supervision of the physician. The proposed rule also allows services for codes 99453-99454 to be provided by supervised clinical staff as well. RPM is not considered a diagnostic service, so it cannot be provided by an independent diagnostic testing facility.

One big change, which is at variance from most guidance on time-based codes, is the time for interactive communication. Historically, CMS has been clear that the time-based requirements consist of a combination of interactive communication, monitoring and management of the patient’s care plan, which is consistent with the code descriptors. In the proposed policy clarification, CMS has taken a different approach to the time component and is only considering the “interactive communication time.”
CMS stated that for purposes of CPT codes 99457 and 99458, interactive communication must total at least 20 minutes over the course of the calendar month for 99457; an additional 20 minutes of interactive communication is needed to report 99458. The interactive communication must have a real-time, synchronous, two-way audio interaction that is capable of being enhanced with video or other kinds of data transmission. The documentation throughout the month must support the time spent to achieve the right coding, but also must separately capture how much of the time was interactive communication, based on this requirement.

Remote patient monitoring codes and descriptions, 2021 proposed

CPT CodeDescription
99091Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring), digitally stored and/or transmitted by the patient and/or caregiver to the physician or other healthcare professional qualified by education, training, licensure/ regulation (when applicable), requiring a minimum of 30 minutes of time each 30 days.
99453Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial setup and patient education on use of equipment.
99454Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.
99457Remote physiologic monitoring treatment management services. Clinical staff/
physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes.
99458Remote physiologic monitoring treatment management services, clinical staff/physician/
other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes.

This CMS’ interpretation would appear to mean that the practitioner and clinical staff must use the RPM, analyze the data, assess it, update the care plan accordingly, and also spend at least 20 minutes talking on the phone or via video with each monitored patient each month. For example, if a doctor spent 50 minutes overall during the month in providing RPM services, but only 17 minutes of that time was actually interactive communication, RPM services could not be reported. If you have been capturing the total time of all services to arrive at your time and codes, this would certainly have a negative impact on how to code, as the time of monitoring and updating the treatment plan would not support the time component of the service. It is anticipated that this change will be one of the most challenged during the comment period.

It also should be noted that under the rule, CPT codes 99453-99454 could not be reported more than once during a 30-day period. Also, monitoring must occur over at least 16 days to be reported. The proposed rule also seems to suggest that 99457-99458 cannot be billed until after the initial 30-day period of monitoring.

All eyes will be on the final rule. Remote patient monitoring is a way for providers to use clinical staff to remotely monitor patients and improve revenue, but complying with these new regulations will not be as easy as it may have appeared during the pandemic.

Achieving Balance Integrity

Jesse FordRevenue Management

In the Age of Consumerism, you need to exhaust all other payment options before the bill goes out

Many years ago, on a flight home from Washington, D.C., I struck up a conversation with a fellow passenger who was heading home with her young son, a boy filled with joy and energy, who was bouncing around his seat like any other child his age. The difference was that he was blind, though you couldn’t tell how or even if this disability was impacting his life.
Nevertheless, the mother slowly revealed the financial burden that caring for her son demanded. It had made her an advocate; she had been in Washington to seek funding for new services for the blind. One of the most revealing stories she shared was about a medical bill she received for more than $100,000 for her son’s care.

Huge bills like that can be accurate, but I also know that such a large balance often reflects a claim error. Financial assistance was not going to help her enough, and she needed to continue to take her child to the hospital for treatment. She had commercial insurance, but her share of the cost was going to bankrupt her family.

The mother spent hours negotiating with her insurer, speaking with financial counselors and the billing office. I imagined how much energy that probably took and was not surprised that nobody she spoke to would or could help her. Amazingly, one day she happened upon the right person, who routed the claim to someone who examined it and contacted the coding department. As it turned out, the services were wrongly coded, so the insurer denied coverage. Documentation supported the use of alternative codes appropriate for the services, so the provider rebilled the claim and was paid by the insurer.

Not everyone is as lucky as my seatmate. This kind of error and its aftermath – savings wiped out and medical debt mounting – is what we at Salud consciously and diligently strive to avoid when we code, bill, and follow up with insurers and patients. Salud has coined the term “balance integrity” to describe the importance of ensuring that patients are billed accurately, but we take it further: We aim to bill patients accurately only up to their financial means and only after we have exhausted every possibility of an insurer paying for the services.

Consumerism demands these changes. People are seeing the cost of employer-sponsored and individual coverage rise, especially out-of-pocket maximums. A recent Urban Institute analysis of census data says at least 3 million Americans have already lost job-based coverage from the pandemic, and a separate analysis from Avalere Health predicts some 12 million will lose coverage by the end of this year.

As cost pressures rise, consumers are looking more closely at medical bills and wondering why healthcare costs so much. This is why regulatory changes aimed at surprise medical bills and price transparency loom on the near horizon.

Balance integrity requires accurate balances. Our definition of an accurate balance is that it matches the insurance explanation of benefits, and the balance does not include anything caused by a billing error. Providers must ensure that claims have been coded accurately, and that each field on a claim form, including modifiers, has been filled in appropriately.

When a provider makes an error, it can expect insurers to deny a portion or the entire claim with a denial that can be complex and easily shifted to a patient to resolve with their insurance. For a large academic medical center, 25% of our accounts have been denied, many with reasons such as “duplicate,” “non-covered,” “coding (error)” or “not medically necessary.” Providers’ payer follow-up staff need to advocate on behalf of patients and ensure that they solve challenging denials instead of transferring the problem to a patient to solve.

Balance integrity means we evaluate and take into account a patient’s ability to pay. For the indigent or people with deductibles and co-pays beyond their means, providers should try to advocate on behalf of the patient with financial assistance, including charity write-offs, discounts, payment plans and perhaps a zero-interest credit card.

If there isn’t someone else who could be billed for services, balance integrity demands we assist patients with finding alternative insurance coverage, such as Medicaid, COBRA or liability insurance.

Balance integrity results in higher payments because most patients do not pay balances that they cannot afford, and insurers tend to pay more than patients. The industry should embrace price transparency rather than trying to sandbag it. If we truly want to be service-oriented, we need to do what’s right for the patient by ensuring that nobody facing a healthcare crisis should also confront the shock of a huge healthcare bill they should not have to think about, much less try to pay.

Succeeding with virtual care: HIT and coding logistics

SaludCoding, Telehealth

A joint presentation from Salud, MedAstute Consulting and Apollo HIT

The operating revenue outlook for most healthcare providers is dire, as patients are only slowly returning to scheduled medical encounters. With the changes to regulations as part of the response to COVID, telehealth services have become a lifeline for many providers.

During the pandemic, hurdles to adopting telehealth have mostly been set aside. The entry costs for providing a simple televisit are low, as long as both parties have Internet and decent Wifi. But this being healthcare, it’s not THAT uncomplicated. There are a host of coding and documentation considerations, and the regulations are far from static.

This session is about the behind the scenes work you need to make telecare a success, now, and we hope long into the future.

Watch the recording | Download the presentation

Revenue cycle faces unprecedented challenges, but old truths point the way to new solutions

Jesse FordCOVID-19, Revenue Management

We’ve done it before.

While we cope with financial and mental stress in an uncertain environment, revenue cycle leaders can draw upon the well of experience they have in adjusting to previous change in our dynamic healthcare industry. We’ve withstood several downturns in the economy. We’ve overcome vast changes in the payer market, reimbursement systems, coding systems and new technology. And we have incorporated groundbreaking new ways to treat patients. We know how to cope with change, and as we reflect on our current state, we should keep focused on the verities that existed before COVID, because they are still here, and in some ways are more profound today.

Patient satisfaction
Our patients may be facing new circumstances, and we need to advocate for them to ensure their experience with revenue cycle is not a source of pain. Generally, I’ve always believed in treating patients with kid gloves, particularly the higher-balance accounts. That truth remains. Anticipate patient pain, help patients find insurance coverage, simplify the process for applying for financial assistance, offer flexible payment arrangements, and make sure that patient balances are accurate and we are not asking patients to solve insurance problems that we are better prepared to handle.

This is a great time to design a model that better marries service with effective collection practices. Our industry has focused on price transparency, as it should, but our model should also aim to simplify how patients navigate revenue complexity, by providing communication and payment options that patients prefer and understand. And, our work today can look for innovative models that boost collections in a patient-friendly way, such as leveraging social psychology, segmentation based upon advance analytics, and/or through a focus on working with patients on the front end.

Employee engagement
Revenue cycle experts are certainly facing new circumstances, as health systems move staff home, ask staff to take on different responsibilities, and sometimes furlough large pools of experienced caregivers. A truth that existed before today’s pandemic still remains; as revenue cycle leaders, we need to ensure our staff are engaged in their work. Engagement is a key to quality, productivity and satisfaction.

Salud helped staff transition to home by establishing virtual “coffee breaks” so that staff take some time to connect. We were lucky to already have a home-based model, and our experienced “at-home” staff shared how they created the best at-home work experience.

From Salud’s inception, we have aimed to design our models to put the right accounts in front of our staff at the right times. We refer to this as meaningful work. Through analytics and robotic process automation, we have continuously reduced repetitive “drone” work, and engaged staff with problems to solve.

Our truth is also founded in treating employees like adults. We give our staff objectives, exceptional training and technology-enabled resources to accomplish goals – and then set them free to get the job done.

Improving cash position
The reality is, nobody was perfect at collecting money before COVID, and we are certainly not perfect today. Reduced volumes caused by the COVID crisis free up some staff time to plug holes. One Salud client reflected that it finally was able to get through special projects such as account cleanups, building edits and working backlogged accounts. It is a great time to catch up, but also to design a model that identifies and addresses holes in the revenue cycle. Some systems are rededicating themselves to denial management, which leads to innovative process improvements throughout the revenue cycle. Others are instituting better ways to identify what they haven’t identified themselves, by auditing zero balance accounts to find gaps in business office processes (e.g., billing mistakes, inappropriate write-offs) and payer underpayments.

Growing with the digital age
Another truth that predates COVID and will endure after it is gone is the need to survive in a digital age. Claims denials and chronic underpayment are age-old problems in revenue cycle, but we can’t just throw endless staff time at these issues. Instead, process automation, analytics and, someday soon, artificial intelligence are means to achieving revenue cycle optimization, which combined with expert staff takes the guesswork out of reimbursement.

These are big challenges, made all the more difficult by COVID. And yet, we’ve done big things before and can do them again.

Evaluation and management changes are coming to outpatient care sites

Jennifer SwindleCoding

The Centers for Medicare & Medicaid Services’ 3-year-old Patients over Paperwork initiative, designed to free doctors and non-physician practitioners to focus more on patient care, has led to the first major revision of evaluation and management (E&M) office visit codes in more than a quarter century. The changes are limited to medical office/outpatient services, but they are significant and will require effort to prepare.

In 2018, the American Medical Association assembled a joint work group representing its Current Procedural Terminology (CPT®) Editorial Panel and the AMA/Specialty Society RVS Update Committee. The group worked with CMS and convened a coalition of 170 state and specialty medical societies to simplify the requirements and make them clinically relevant. One of the main goals is to reduce the administrative burden by getting rid of redundant and/or unnecessary documentation in the medical record that does not have a meaningful impact on actual patient care.

Obviously, much has changed since the 1995 and 1997 versions of E&M. Those could not have anticipated the impact that electronic health records would have on provider documentation. Healthcare today is more focused on patient needs and utilizes a team model not seen as much that many years ago.

Medical necessity still critical
One thing that has not changed and is not impacted by the changing guidelines is that medical necessity should be the overarching criterion for determining the level of service.

The big changes to E&M are:

  • The level of service will be determined either by medical decision-making or by time
  • Elimination of CPT code 99201 for new patient visits. There will be no variation from new to established patient for documentation content, medical necessity or medical decision-making.
  • History and examination documentation will not be factored into determining the level of service

Significant changes were made in how to determine the medical decision-making component to correlate it with medical necessity. Extensive edits were made to the elements for code selection, including removing ambiguous terms such as “mild” and clarifying “acute or chronic illness with systemic symptoms.”

Recalculating total time
The other methodology to capture the correct level of service is based on the total time, which includes both face-to-face time and non-face-to-face time that is specific to the patient’s total care for a particular day of service, but no longer needs to have a counseling component. It is the time personally spent assessing and managing the patient on the date of the encounter and includes:

  • Preparing to see the patient (e.g., review of tests)
  • Obtaining and/or reviewing separately obtained history
  • Performing a medically appropriate examination and/or evaluation
  • Counseling and educating the patient/family/caregiver
  • Ordering medications, tests and procedures
  • Referring and communicating with other healthcare professionals (when not separately reported)
  • Documenting clinical information in the electronic or other health record
  • Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
  • Care coordination (not separately reported)

While this is a CMS change only, we at Salud will be monitoring the commercial payers closely to see if they adopt the new methodology, and you should too. Also, you must keep in mind that it impacts only a few of the E&M services, and there will still be a need to follow the current existing guidelines for other types of E&M services, so there will potentially be dual rules dependent upon payer and setting.

Different providers will be impacted differently. Those who provide most services in an inpatient setting, such as hospitalists and intensivists, will see no change, while providers that function nearly exclusively in an outpatient or office setting will have significant change.

Understanding the changes, educating on the changes, and monitoring successful implementation will be necessary. Salud will be offering presentations on the E&M changes to industry groups and will certainly work with coding clients. The AMA offers tools and resources to help practices transition to the new reporting guidelines that take effect Jan. 1, 2021. That includes a checklist to help guide a practice through the E&M changes.

January 2021 is not far off, so the time to start training is now.

Want some good news? Start with recovered cash today, and much more to come through automated processes and understanding of payer behavior

Frank MassiRevenue Management, Zero balance

Despite the return of elective procedures at most hospitals and outpatient centers, not nearly enough patients have been showing up, perhaps fearful of what they perceive as high-risk environments. As a result, healthcare’s COVID-19-fed economic downturn has reached epidemic proportions, leaving organizations of all types and sizes scrambling to identify any new or accelerated sources of revenue.

Instead of mass layoffs or furloughs, some forward-looking health systems are seeking cash-yielding solutions that are non-disruptive to current operations. They are looking beyond COVID-19’s impact for lasting positive effects on cash and efficiency. Here are four tactical and strategic priorities that should be pursued simultaneously right now:

  • Take advantage of the opening presented by the dramatic and sudden reductions in volumes and shifts in account mix due to the COVID-19 crisis to design and implement a new business office operating model that effectively “future-proofs” cash
  • Use reviews of past and prospective payments analysis to discover and recover significant new cash
  • Take the low-risk approach of choosing projects completely unaffected by the crisis so staff can stay focused on their own related urgencies
  • Short-list only those vendor partners who will perform the work completely at-risk and with no upfront fees

These are not mutually exclusive objectives. And now is the perfect time to address all four in a single project with a single, at-risk vendor partner.

When zero means quick cash
At a time when many institutions are in the midst of a severe revenue downturn, seeing a cash recovery of $110,000 in the first month, and more than $727,000 in just over three months, as a 450-bed hospital client of ours did recently, or $4.8 million in four months, as a large Midwest hospital received, is much needed good news.

This process, known as zero-balance reviews, involves both a retrospective and prospectively modeled look at paid and/or written-off claims. These reviews of closed accounts use a process of reimbursement analysis followed by the grouping and analyzing of like claims to find out why some are underpaid and where there may be significant trends that convert to large sums of recovered cash immediately. As importantly, it identifies the underlying issue(s) and corrective actions to take. As a result, tens of millions of dollars in future revenues have been protected from leaking away into a river of red ink.

Zero balance reviews will pay even larger dividends when normal volumes return. Much revenue leakage is caused by providers failing to code and bill according to payer rules; analysis of payment to charges catches accounts paid properly per payer contracts but underpaid as they were coded incorrectly.

Automating denial management
If you are a health system with a robust denial management system, many of your claims look right. If you are a health system with a robust reimbursement analysis program, many of your claims will be paid according to how they were billed. Working with a partner with an effective coding team and an AR team that understands the payer market across the spectrum will show you why and how those claims were underpaid. Working with a partner that can also detect errors across the full spectrum of your revenue cycle operation will show you why and how to lift performance across the board front-to-back.

Using advanced automation in the review process means that thousands of claims can be reviewed instead of a few dozen per day through manual processes, which removes the only viable objection to zero balance reviews – that they involve many small balances not seen as worth a lookback by staff straining to handle new claims.

Salud isn’t the only vendor out there that does this work, but we have turned it into a tech-enabled specialty. Our process includes:

  • Contract modeling, automated claims status reports, and historical 835 electronic payment explanation data to find zero balance accounts with recovery opportunities
  • SaludSynapse, our business intelligence platform, provides rules-driven workflow that streamlines the appeals process and maximizes results
  • Sophisticated analytical reimbursement models are built specifically for all the national payers and tuned smartly to each state’s payer rules and tendencies

Audits find root causes of underpayment
Salud expands the net by finding underpayments as a result of many other breaks in the process like coding, billing, and as a result of analysis of percent of charges ratios. Other solutions also do not have our technology-enabled workflow, intricate knowledge of national and local payer practices, or our data mining and analysis tools.

The fact that zero balance reviews are non-disruptive even amid the pandemic is a huge bonus. They are unaffected by the huge shift in AR to non-elective procedures due to massive procedure cancellations as well as labor shifts and reductions in business office staff or coding.

Regular audits of the business office through this program provides well-articulated root causes of underpayment. Processes and systems are calibrated to address the inevitable challenges brought by the interdependencies and continually evolving roles of business office people, process and technology, thus protecting future revenue streams.

The time to deliver cash for current operations is now, with an even bigger payoff to come.