Medical insurance billers (MIBs) once dreamed of a modern way to submit claims that eliminated paper records and allowed claims to arrive almost instantly at their destination.
With electronic medical record (EMR) technology, the future is now. In this informative article, EMR expert, Nitin Chhoda, explains what billers need to know about electronic claim software.
MIBs have the option of purchasing billing software or an EMR for their company’s needs. EMRs offer a wider range of functionalities for use in the 21st century medical billing enterprise.
Modern and convenient, they provide the critical security measures and protections mandated by HIPAA for the transmittal of reimbursement claims.
Counting Costs
Medical billing software costs range from $500 to $5,000. EMR technology can be obtained from reputable sources, with monthly user fees as low as $49. Both types of software systems accomplish the same objective, but EMRs offer other functionalities that can make a biller’s job easier and enable them to offer additional services.
Claims and Security
The Affordable Health Care Act mandates that billers submit reimbursement claims electronically. Claims that aren’t will be denied. Submissions must also conform to HIPAA security regulations for transmitting medical data. EMR software complies with both of those goals, has built in safeguards to protect patient information, and will alert everyone within the network in the event of an attempted breach.
Coding and Billing
The upcoming transition to ICD-10 codes has many in the medical field concerned about revenue disruption. Electronic medical records are capable of handling the addition of all the new codes and insurance plan modifications with efficiency and finesse, including those used outside the U.S. Most billers won’t encounter the foreign coding, but an EMR allows MIBs to be prepared.
Billers must implement HIPAA’s 5010 transaction standards for digital transmissions before utilizing the new codes.
Document templates can be created for any practice or specialty with an EMR, and can be modeled on documentation with which staff members and billers are familiar. The systems can be integrated with other clinicians, pharmacies and medical facilities for referrals, prescriptions and diagnostic testing. The full complement of documentation is available to billers for clean claims that are approved quickly.
Modern Communications
Many billers are tasked with monitoring and tracking the financial accounts of their clients’ patients.
An EMR allows MIBs to communicate with patients through multiple means that includes phones and mobile devices, mail and email, and text and voice messages.
MIBs can remind patients about outstanding balances and monitor if deductibles and co-pays have been met.
Electronic claims are no longer a futuristic dream. They’re available now with instantaneous and secure transmissions that conform to the Affordable Health Care Act and HIPAA.
The multi-functionality of EMR software allows MIBs to painlessly integrate the new ICD-10 codes, collect client revenues quicker, and offer all the services practitioners require.
If you are not using an EMR system already, then the time to consider it is now. That’s not all. You want to ask the important question “Is my EMR system recognized and tested by the Office of the National Co-ordinator (ONC) and how can I verify this?”.
Healthcare is changing and practitioners must transform their practices to remain in business.
Government Sanctioned EMR Technology
We’re living in a new world, and I call it the “Obamacare Economy”. As a clinician, it’s your responsibility to document, code and bill effectively, and make sure everything is reported to CMS and other payers. You can achieve this the hard way with pen and paper, or the easy way with EMR technology.
Even through physical therapists are not ‘eligible professionals’ and therefore not eligible for Meaningful Use incentives like physicians, physical therapists should consider using (at minimum), a base EHR certified technology from January 1, 2014 to be eligible for PQRS incentives, according to a CMS Rule published 11/16/2012 that can be found here:
“Therefore, based on the comments received, we are also finalizing to the requirement that a direct EHR product be certified by ONC as Certified EHR Technology (CEHRT), and therefore meet the definition of CEHRT in ONC’s regulations (see 45 CFR 170.102), to submit PQRS measures. (For the 2014 Edition EHR certification criteria, please refer to 77 FR 54163)”
“We are discontinuing the qualification process and requiring that a direct EHR product be CEHRT beginning in 2014. A certified quality reporting module may be part of CEHRT, but CEHRT as a whole is more comprehensive. Please refer to ONC’s standards and certification criteria final rule for additional information on requirements for CEHRT (77 FR 54163).”
A CEHRT is defined as “EHR technology certified to the 2014 Edition EHR certification criteria that meets the Base EHR definition and would support the objectives, measures, and their ability to successfully report the CQMs, for the MU stage that they seek to achieve.”
These are the minimum modules that an EMR must be certified in to meet the requirements of being a CEHRT and being able to directly submit PQRS in 2014.
Includes patient demographic and clinical health information, such as medical history and problem lists
Demographics § 170.314(a)(3)
Problem List § 170.314(a)(5)
Medication List § 170.314(a)(6)
Medication Allergy List § 170.314(a)(7)
Has the capacity to provide clinical decision support
Clinical Decision Support § 170.314(a)(8)
Has the capacity to support physician order entry
Computerized Provider Order Entry § 170.314(a)(1)
Has the capacity to capture and query information relevant to health care quality
Clinical Quality Measures § 170.314(c)(1) through (3)
Has the capacity to exchange electronic health information with, and integrate such information from other sources
Transitions of Care § 170.314(b)(1) and (2)
Data Portability § 170.314(b)(7)
Has the capacity to protect the confidentiality, integrity, and availability of health information stored and exchanged
Privacy and Security § 170.314(d)(1) through (8)
The EMR software you use must satisfy these criteria, and must be tested and accredited by one of the four bodies approved by the ONC.
ONC Certified Base EHR Technology – Is Your Vendor Certified by one of the ‘Big Four’?
The Office of the National Coordinator for Health Information Technology is responsible for certifying electronic medical records software, and it does so through FOUR ‘Certification Bodies and Testing Laboratories’, which play a key role in the ONC HIT Certification Program.
Certifying and testing Electronic Health Record (EHR) technology provides assurance to providers and other purchasers that an EHR system offers the necessary technological capability, functionality, and security to help them meet the Meaningful Use criteria, and helps maintain quality and consistency across the certified products. Once again, physical therapists are not eligible for Meaningful Use funds, but a minimum ‘base EHR’ technology is required for reporting PQRS measures.
In the ONC HIT Certification Program, ONC-Authorized Certification Bodies (ONC-ACBs) conduct certification and Accredited Testing Laboratories (ATLs) conduct testing.
A single organization can be both an ONC-ACB and an ATL. ONC has authorized the following certification bodies to serve as ONC-ACBs in the ONC HIT Certification Program:
Certification Commission for Health Information Technology (CCHIT)
Drummond Group
ICSA Labs
InfoGard Laboratories, Inc
Only test tools and test procedures that have been approved by the National Coordinator can be used to test Complete EHRs and/or EHR Modules in order for them to be eligible for certification by an ONC-Authorized Certification Body (ONC-ACB). ATLs are authorized to test Complete EHRs and/or EHR Modules according to the 2011 and/or the 2014 Edition EHR Certification Criteria.
The test tools and test procedures that align with the 2014 Edition are available here
On this site, providers can access all certified software and select individual products or combinations of products to use to attest for Meaningful Use funds through the CMS. Providers can also look for EHR vendors that have been tested and certified for certain specific criteria (these will appear as ‘Modular EHR’ technologies).
Try it out by selecting a 2011 or 2014 Edition software, placing it in the shopping cart, and see the resulting message that is generated.
What this Means for Physical Therapy Private Practice Owners
Physical therapists who bill Medicare must report PQRS measures (and Functional Limitation G codes) to avoid penalties and the best way to do this is with the use of an EMR system. Your EMR should be a registry, or provide claims based reporting options to CMS, or better yet, be recognized by the ONC as a ‘Modular EHR’ that fulfills the requirements of a ‘base EHR’.
Technology like this offers the ability to collect reimbursements quicker, maintain security compliance, and increase the profitability of practices.
EMR systems contain functionality to track multiple variables that affect the practice and market services successfully. The software can be deployed on tablet technology for portability, allowing therapists to save time during the patient encounter and complete paperwork electronically for quicker billing turnaround.
The EMR technology of the future must help grow your practice. It’s not enough for an EMR vendor to be ‘just another vendor’ that sells you software for scheduling, documentation, compliance and billing. It’s not enough for the software to have perks like appointment reminders and home exercise programs.
Your practice needs way more than that to be able to help you grow in the Obamacare economy, and that’s why we built In Touch EMR.
Your EMR software has to go above and beyond what it’s doing now.
It has to help you increase profits by integrating all the following within the interphase of the EMR software:
Increase referrals from physicians with automated marketing systems
Increase referrals from patients with automated newsletters, greeting card, phone, text and email communication systems
Increase referrals from other business in the community by creating and automating cross promotion marketing campaigns
Converting prospects to patients with done-for-you educational resources automatically distributed to patients
Diversification – The Way to Thrive in this New Economy
In this new economy, you don’t want to ‘keep all your eggs in the Medicare basket’. As patients see a decline in the quality of physical therapy, they will be looking for (and willing to pay for) options that make them healthier.
This is an unprecedented new opportunity, unlike anything we’ve ever seen before in physical therapy private practice.
That’s exactly where you come in.
Today’s patient is eager to partake of services and products perceived as “luxury” items. Known as cash paying services, they’re paid for at the time they’re delivered. Options include selling supplements, durable medical supplies and medical products to better serve patients and create multiple income streams.
Hiring the right staff to provide the services, and the right systems to be able to track these services is the first step towards diversification. Speaking of systems, nothing is more important than a simple, yet powerful electronic medical records (EMR) system for your private practice.
With the portability of EMRs, practitioners can expand their repertoire of offerings at the clinic and in other venues. Clinicians can feature a variety of different massage therapies, weight loss clinics and nutritional information, along with personal training,acupressure and wellness programs. Aquatic therapy, women’s programs, athletic training services and fall prevention offerings are also popular.
Your Action Plan with Obamacare
Strategies to maximize Medicare payments include:
Be more efficient with time spent with all patients, especially Medicare
Be more knowledgeable about the types of CPT codes and number of units billed
Here is how you can maintain (and even increase income) in the Obamacare economy:
Diversify your payer mix by having payers other than Medicare, preferably those who pay more than Medicare. Look at your payor contracts to determine how much you are getting paid and identify the ones where you are paid more. Reduce your dependence on Medicare patients. We can help you analyze this, as part of our coaching service in the Referral Ignition Elite program.
Setup different cash paying programs to increase income and increase lifetime value of each patient. Mobilize your staff, patients and referral sources to help you increase referrals and grow the practice. Diversify sources of income and services to serve patients better to make your business multi-faceted and diverse. You can get several free tips and tricks on how to market your private practice at our blog.
Clinicians must be more efficient in the time they spend with patients, from ascertaining the source of their ailments and creating documentation to preparing claims for billers.
Besides the clinician, the biller is the most important person in the practice. Here are some of the most time consuming aspects of billing:
Creating claims by copy pasting ICD, CPT, modifiers, supporting diagnosis data into the billing software
Editing and scrubbing this data before it is submitted to the payer
Manually batching claims and uploading them to the clearing house
Manually reviewing and posting ERAs to the patient record
Submitting secondary claims
Generating and mailing patient statements
Here’s the good news – EMR systems such as the In Touch EMR and the fully integrated In Touch Biller Pro automate all of these tasks for the biller. This allows the biller to focus on the things that drive revenue for the private practice such as:
Make sure all claims are submitted as quickly as possible
Identify reasons for denials and eliminate them
Provide simple guidelines to clinicians to maximize reimbursement and minimize denials
Call the insurance companies to follow up on claims
Make sure all EOBs are entered promptly
Write and mail appeal letters
Follow up with patients to make sure statements are paid
This makes things easier for the private practice owner, allowing him or her to plan and implement diversification endeavors.
Concierge Services – A Bold New Alternative
Concierge practices, also known as direct pay practices, are typically the bastion of primary care physicians, but the concept can work for physical therapists. In a concierge practice, patients pay a monthly or annual fee for enhanced services that can include same day appointments, email consultations, extended patient encounters and 24/7 access to their therapist, along with other perks.
Practitioners generally maintain a smaller roster of clients, but are paid better and work fewer hours. It’s a healthcare option that enables clinicians to practice in their own way, reduces staffing, compliance and administrative costs, and treats patients as individuals rather than part of an assembly line. Therapists can also continue to accept insurance payments if they choose.
Therapists don’t want to turn away any patient, especially those with Medicare who may need them most, even though they’re underpaid through Obamacare.
To combat the negative impact of Obamacare on patients and practitioners, clinicians must increase the efficiency level during the patient encounter.
Identifying cash paying services and products appropriate for the practice allows clinicians to attract a larger and more diverse clientele. Those services and products will establish multiple streams of revenue that ensures profitability through any economy and helps practices survive Obamacare.
Medical billing is experiencing unprecedented growth compared to other professions. A variety of misconceptions and unrealistic expectations have accompanied that development.
In this revealing article, physical therapist and electronic medical record (EMR) specialist, Nitin Chhoda, examines the misconceptions associated with a medical insurance billing business.
Home-Based Billing
As the demand for medical insurance billers (MIBs) has grown, so has the number of scams promising individuals enormous incomes with no experience needed.
Despite advertisements to be found in multiple media outlets, there is no such thing as a home-based biller.
No medical provider will allow sensitive information to leave the office for someone to toil over like medical billing homework. While there aren’t home-based billers, there are medical insurance businesses that are operated from the biller’s home.
Education
Despite claims to the contrary, a career in medical billing requires specific skills. MIBs must demonstrate a level of competence to become certified that requires a myriad of specialized knowledge. Would-be billers can’t learn as they go and should seek appropriate educational venues.
MIBs will need a working knowledge of ICD-10 and CPT codes, anatomy, clearinghouses, and both commercial and government-funded insurance programs.
Short Hours, Big Pay
Medical billing isn’t a way to get rich quick. Don’t expect to make $40 an hour or $50,000 in the first year. Those claims are the tools used by scammers. MIBs typically make $11-$20 an hour, depending on their level of experience. Entrepreneurs should be aware that the company may not make a profit in the first year, or even the second.
Launching a new business is time consuming. Operating a business from home provides individuals with the flexibility to set their own hours, but shepherding a new business to success is time consuming. Fledgling business owners should be prepared to put in a lot of long hours. Medical billing is a year-round job.
Motivation
Certified medical billing people that choose to go into business for themselves are responsible for every facet of their enterprise and they must be self-starters. There will be no supervisor watching a time clock or conferring assignments. Working at home is convenient, but it can also be distracting. MIBs will need to be organized and learn to manage their time wisely.
More than Numbers
MIBs do more than just type numbers in a form on a computer. They verify information, check for appropriate coding and transmit reimbursement claims.
Medical billing staff also monitors claims that have been paid and those that haven’t, along with posting payments to client accounts and providing friendly reminders for patients with balances due.
Billers shouldn’t expect to sit home alone with their computers. They have to interact with others in person and via phone.
Medical insurance billing is one of the fastest growing career opportunities available and unscrupulous individuals have taken advantage of that to sell impossible dreams and expectations. Anyone who wants to launch a medical billing firm should begin with the necessary education and be willing to put in long hours to grow a respected and reputable business.
One of the primary attractions of a career in the medical insurance billing (MIB) profession is the low startup costs compared to other businesses. Most MIBs plan for big expenditures, but fail to figure in small but essential costs.
In this insightful, two-part article, Nitin Chhoda examines the cost of doing business and what MIBs can expect to spend when they open their own business.
MIBs typically begin by operating their business from home to save on costs. Renting office space is a major expense that can cost thousands of dollars a month depending on the location.
To equip a medical billing business with the basics will require approximately $5,000 and there are numerous ways entrepreneurs can reduce their costs. Keep in mind that prices fluctuate among retail outlets and geographic areas.
Computer System
It can be tempting to purchase the most expensive medical billing business model available, but a good computer system that includes the hard drive and a minimum of a 19-inch monitor can be obtained for approximately $2,000. A 19-inch monitor will help prevent the eye strain of being in front of the computer for eight hours a day.
The operating system must be the latest version of Windows to be compatible with medical billing software.
A multi-function machine, often called an all-in-one, is capable of printing, scanning, copying and faxing. All of the capabilities will be required as part of the medical billing process. A basic model can be purchased for as little as $100.
Medical Billing Software/EMR
MIBs have a wealth of medical billing software from which to choose. The software represents a major outlay for a fledgling business. MIBs can expect to spend around $700 for medical insurance billing software, though there are systems that cost thousands.
Another option is EMR software that provides all the capabilities required for medical billing, communicating with clearinghouses and maintaining HIPAA compliance when dealing with patient data.
Fully functional EMR systems are available and only require a modest monthly fee. An EMR that has built in security features, is easily updated when needed, can handle the full range of ICD-10 codes, and can be used to create CPT code databases to reflect client specialties.
Clearinghouse Contracts
Medical billing businesses will be required to contract with a clearinghouse, which allows them to submit client claims for reimbursement. The average cost is $300. MIBs should be prepared for the need to purchase additional software for complete clearinghouse compatibility or to offer clients extra services, an expense that can run around $350.
Printed Material
Manuals and reference materials for medical billing business will account for $200-$300. They encompass coding manuals, insurance directories and disease classifications, along with medical terminology and the intricacies of submitting claims.
Available in book form, many are also offered as CD-ROMS that can offer valuable savings. Part of the reference library should include books on marketing the business.
A career in the medical insurance billing field is one of the few professions that require a minimum of investment by entrepreneurs.
Computers, software, reference material and clearinghouse fees represent the major financial outlays, but there are many smaller costs of which MIBs may not be aware. In the second part of the series, Chhoda will explore the smaller, but no less important costs of launching a medical billing service.
The goal of the Patient Protection and Affordable Health Care Act was fourfold: to increase access to healthcare, reduce healthcare costs, institute more consumer benefits and protections, and improve efficiency. As different portions of the Act go into effect, it will have a major impact on virtually every individual in the U.S.
The Act has both a human and financial component.
According to the Center for Disease Control (CDC) more than 45 million people had no type of health insurance in 2012.
Individuals at the lower end of the financial spectrum were the most likely to lack coverage.
The Congressional Budget Office estimates the Act will reduce the number of uninsured by 27 million between now and 2023, but will still leave approximately 26 million Americans uninsured and financially unable to purchase coverage.
Increasing Access to Healthcare
Obamacare establishes healthcare exchanges and provides subsidies for low income individuals to help them purchase coverage. Millions of Americans can stop living in fear of becoming ill.
They will no longer be turned down for a preexisting condition and children can remain on parental policies through the age of 26.
The downside is an influx of new patients to practices that are already working to capacity. A poll for the Physicians Foundation showed that 40 percent of medical professionals intend to sell their practice or retire early due to Obamacare, resulting in a shortage of available clinicians and longer wait times to obtain an appointment.
Reducing The Cost of Healthcare
One of the tenants of Obamacare was the control and reduction of skyrocketing healthcare costs. The Act reduces the amounts paid by Medicare to practitioners, but allows hospitals to collect more for the same services.
The inequity is prompting many clinicians to stop accepting Medicare patients, further limiting access to care.
Clinicians are under pressure to reduce the number of tests they order and utilize the least expensive modes of treatment whenever possible. Many healthcare professionals fear the drastic reductions in reimbursements will drive potential physicians into other fields.
Healthcare costs also come in the form of copays, premiums and deductibles. Patients are already seeing an increase in all three, as insurance companies raise prices in response to the services the Act forces them to reimburse for.
With insurance companies placing limitations on reimbursements, pharmaceutical firms are reducing or eliminating medications as unprofitable to produce.
The cost of Obamacare comes in other guises. In 2018, a 40 percent tax will be placed on healthcare plans, dependent upon their value, and collected through tax returns. Fines will be assessed on individuals without insurance.
Employers with more than 50 workers must offer insurance or face financial penalties for each person they employ.
Benefits and Protections
Obamacare provides patients with some perks along with coverage. Insurance companies can’t place an annual limit on benefits, nor can they cancel policies for frivolous reasons, but the Act limits the amount individuals can place in Flexible Spending Accounts (FSAs) and purchases that can be made with the funds.
Improving Delivery and Efficiency
The Act’s components are intended to increase the overall efficiency and delivery of healthcare services. To accomplish that goal, the Act mandated use of an electronic medical records (EMR) system.
The technology is expected to allow clinicians to treat a greater number of patients per day and eliminate paper records.
Accountable Care Organizations (ACOs) encourage networks of providers, with financial incentives for clinicians that provide a better level of care.
The focus of healthcare would begin a transition to a system of preventatives measures rather than reacting to treat disease after it occurs.
The Act also creates a panel of individuals to determine and recommend preferred treatment options.
Obamacare has four major goals through the Affordable Healthcare Act. In an effort to solve the glaring problems in the healthcare system, it will change the way clinicians practice their profession and deliver care. Patients will have greater access to clinicians, but only time will tell if Obamacare creates a nation of healthier individuals and more efficient practitioners.
Practitioners are always seeking new sources of revenue and skilled medical billing specialists can obtain those additional funds through entirely legitimate means. Medical billing isn’t confined to simple coding procedures alone and in this insightful article, Nitin Chhoda examines ways billers can create greater cash flow for the practice.
Needful and Medically Necessary
There exists a wide range of procedures and modifiers that insurance companies don’t cover. They’re considered cosmetic and viewed as elective treatments.
Depending on the procedure, it may be possible to obtain reimbursement for some of those procedures, such as reconstructive surgery. Obese patients who have lost massive amounts of weight may require loose and excess skin to be removed.
Other clients may need dental work that can be billed as a covered expense, along with rehab services. Practitioners should remember that health concerns aren’t limited to the physical body. Patients may need the services of counselors, psychologists and psychiatrists to treat the mind.
Equipment and Pharmaceuticals
Modifiers are essential if more than one medical provider is involved and can qualify for additional payment. If it’s necessary to obtain lab work, an x-ray, MRI or similar diagnostic services, chances are the patient will be sent to another provider or facility. Equipment owned and maintained by another entity can be billed using modifiers.
Unbundling Advantages
Procedures that require extra skill, effort and time may qualify for additional reimbursement. Medical billing staff can billed specific services separately through the application of the appropriate codes, edits and modifiers. Practitioners may find that they must perform a second procedure while conducting another. Sometimes the two can be linked, but not if the second procedure is essential to the first.
Modifiers and Edits
Sometimes the difference in reimbursement is as simple as adding the correct modifiers to explain the full extent of the clinician’s services.
For instance, clinicians who make a simple diagnosis of a head fracture will receive much less in reimbursements than a practitioner that enters a diagnosis of a closed head fracture with contusions and lacerations. Each diagnosis is correct, but one provides greater detail and modifiers, allowing billers to enter that information in a way that generates a larger reimbursement.
Same Day and Multiple Treatments
Patients no longer rely on a single healthcare provider for all their needs. When a client sees multiple clinicians on the same day, modifiers are sometimes necessary to indicate each practitioner provided different services
Modifiers indicate a change or alteration in how a procedure or service was delivered. When use of modifiers is justified, it can mean a difference in hundreds and even thousands of dollars each year in additional revenues. They must be utilized judiciously. If not, it can result in paybacks and even legal action.
Supplies, Consultation and Time-Based Coding
A bandage may seem like a small concern, but some clinicians are depriving themselves of income by not including medication and supplies that are dispensed in the office.
The same is true when practitioners provide patients with counseling about medications, treatment options, and coordination of care that accounts for 50 percent or more of the patient encounter.
A complete accounting for the time spent must be documented to prove the service was necessary
One of the largest concerns of payers is fraud and inflated claims. They’re job is to find ways not to pay claims, or as little as possible, which often leads to underpayment for clinicians. With justified use of modifiers and edits, unbundling and hour-based billing, billers can legitimately stimulate significant cash flow for any practice.
