It entails using technology to keep track of the claims process at every point of services, so that the healthcare provider can follow the process and address any issues, allowing a steady stream of revenue.
Elements in Physical Therapy Billing
Time management and efficiency play large elements in physical therapy, and a practitioner’s choice of an EMR can be largely centered on how their physical therapy billing is implemented. Some of the processes handled with physical therapy billing software include:
Streamlined scheduling that allows your office to verify patient’s coverage and benefits before the visit. This helps you in deciding whether to use the patient’s insurance coverage or ask for another source of payer.
Faster payments through the check in/out process via patient and medical insurers
Enhanced compliance with up to date standards so thatyour practice stays current with HIPAA rules, regulatory compliance, and implementation deadlines. Updated information is automatically downloaded and is free.
Managing the revenue cycle will bring more visibility, make compliance simpler, and make the physical therapy billing team more productive.
New physical therapy EMRs provide revenue cycle management solutions that are very successful at improving efficiency.
With a fully integrated and mobile EMR and physical therapy billing, you can reduce the entry of patient information to a single occurrence, and it will happen when the patient picks up the tablet computer and enters their information.
Mistakes in the billing and coding process can take many forms, from incorrect ICD coding to ethical violations. In this revealing article, Nitin Chhoda examines the most common errors facing billers and coders, and identifies ways to avoid them.
Billing and codingspecialists work with protected information every day. Their actions have an impact on their employer, payers and patients. It’s essential that they maintain the highest ethical standards and are cognizant of laws that could inadvertently be broken.
Billing and coding staff work with facts that are backed up by practitioners with documentation. Never assume and don’t include codes that are only implied.
Appropriate documentation must accompany every claim and support the clinician’s diagnosis and treatment. Neither should codes be unbundled to claim additional reimbursement. Codes should accurately reflect the patient encounter.
The Blame Game
If a mistake is made, accept the blame instead of trying to foist it off on another billing and coding staff member. If a problem exists in the claims process, address the situation with the appropriate individual.
Many practitioners record every action during the patient encounter, but that doesn’t mean every detail is billable. Only claim procedures and treatments that are supported by documentation and don’t second guess the clinician. If doubts or questions exist, clarify with the practitioner.
Some actions are incidental to specific procedures and shouldn’t be billed separately. Learn which procedures can be bundled and which ones can’t to ensure accurate billing and coding.
A mistake can be anything from an omission or incorrect code to a transcription problem. When errors are discovered, they should be brought to the practitioner’s attention. Fix the problem immediately and submit a corrected claim. Ignoring an error can result in payments to which the clinician isn’t entitled and opens the door to fraud.
Even when claims are submitted correctly, errors can occur in billing and coding that result in over payments. The payer should be notified of the mistake immediately. Be prepared to follow the necessary procedures to return the funds. Doing so reinforces the practice as a desirable partner.
Failure to Protect Patients
Clients may be required by their insurance company to only see certain providers within the payer’s network. Failure to do so can result in costs the client can’t pay and no reimbursement for the clinician. Patient coverage and benefits should be verified by billing and coding staff before their visit.
If there’s a problem, the client can be advised of their options prior to treatment.
More payers are demanding pre-authorizations before they pay for services. Failure to obtain the appropriate authorizations or referrals can result in billing and coding claims being denied and loss of payment for the provider.
The law protects patient information and anyone who discloses personally identifiable data is in violation of HIPAA regulations. Penalties for violations include significant fines and jail time. It’s imperative that all staff members, including those in medical billing and coding, are aware of HIPAA laws and consequences of breaking the patient’s trust.
Some billing and coding managers aren’t as cognizant of coding rules, procedures and penalties as they should be, and they may even urge those in their charge to ignore or overlook issues.
Don’t be afraid to report such matters to the manger’s superior.
Mistakes are inevitable, but they should be rectified immediately. Precautions should be taken to protect patient information and uphold the highest of ethical standards to protect the integrity of the billing and coding staff, and the practice.
Medicare is the biggest government payer practitioners will deal with, but it’s by no means the only one. Government-operated health insurance encompasses many other programs and in this second of a two-part series, Nitin Chhoda addresses other government-sponsored insurance plans.
Healthcare insurance programs operated by the government provide coverage for veterans, low-income adults and injured workers.
Managed by the federal government, some programs are administered at the state level.
All have very specific regulations and can require pre-authorizations, referrals, and proof of medical necessity before they approve reimbursements.
Next to Medicare, Medicaid is one of the best known healthcare insurance programs in the U.S. Designed to provide the poor and low-income individuals with basic health services, it’s administered at the local level. Each state has considerable leeway in the manner in which it administers the program, determines individual eligibility, and what services are provided.
Funding cuts to Medicaid at the federal level has resulted in many states limiting coverage to the most basic levels for adults. The program also provides limited healthcare coverage for those who require nursing home care. Children in the program receive dental and vision services, along with healthcare. Medicaid patients are entitled to surgical procedures, inpatient hospital treatment, and prenatal care.
It’s extremely difficult to verify a patient’s Medicaid eligibility, what portion of the bill the client may be responsible for, and what services are covered until the actual reimbursement claim is submitted. Medicaid maintains a stringent fee schedule, regardless of actual costs.
Funded by the U.S. Department of Defense, Tricare is the healthcare plan that serves active military personnel and their dependents. Tricare encompasses three levels of care – Standard, Prime and Life. Tricare Standard is for active duty, retired and reserve retirees, and their family members. It operates similar to a PPO. Recipients are required to pay a deductible and copay, but can see any civilian healthcare provider.
Tricare Prime resembles an HMO and serves the same segment of the military as the Standard. Patients have more restrictions and must only utilize network providers. Tricare for Life is a supplement plan for former Tricare members that are eligible for Medicare. The plan pays according to a fee schedule similar to Medicare.
The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) serves VA patients and those not eligible for Tricare, along with spouses and dependents of military personnel who were disabled in the line of duty. Surviving spouses and dependents of veterans killed due to military-related injuries are also eligible.
CHAMPUS healthcare plans are usually secondary payers. When it’s the primary payer, the plan functions much like an HMO. It’s imperative that coverage is verified prior to the client’s visit to ascertain if a referral or pre-authorization is required before treatment is provided.
Administered by the U.S. Department of Labor, Workers’ Compensation is available for workers injured while on the job or who develop an occupation-related disease. Practitioners must enroll in the healthcare program and obtain a DOL number.
Workers’ Comp claims always require pre-authorization, but that doesn’t guarantee payment for services.
Before treating a client, verify pertinent information about the disease or injury with the employer. A diagnosis code must be approved by the Workers’ Comp carrier and the medical provider must prove medical necessity.
Clinicians should obtain a pre-authorization for every procedure. Workers’ Compensation claims are paid according to a healthcare pre-determined fee schedule, and funds deposited through electronic fund transfer.
Patients covered by government-operated healthcare programs can add significantly to the revenues of any practice, but clinicians should exercise caution especially with their medical billing and make sure to verify every aspect of the client’s coverage prior to treatment.
Government healthcare plans have numerous rules, regulations and filing requirements and if they’re not followed to the letter, reimbursements won’t be forthcoming.
Clearinghouse represents the first step on a reimbursement claim’s journey toward money in a clinician’s pocket, but a lot can happen once it’s transmitted from the practitioner’s office.
In this revealing article, Nitin Chhoda provides an inside look at factors that can affect a claim and the ultimate reimbursement.
Before And After
A clearinghouse is an essential element of the entire medical or physical therapy billing cycle. They ensure that each claim is routed to the appropriate insurance company for payment.
They perform other useful functions before a patient arrives at the office and afterward. Billers can utilize their services to ascertain a client’s insurance eligibility and coverage prior to treatment. They can also issue a statement of services to patients.
Cleaning the Claim
The first step for a claim after its arrival at the clearinghouse is a thorough scrubbing for errors and inconsistencies. Some mistakes can be quickly corrected online, allowing the claim to continue on its journey. These are typically clerical errors and while they may seem minor, they contribute significantly to the wait time for the claim to be paid.
Other problems aren’t so easily rectified and the entire claim will be returned to the clinician’s office to be corrected and resubmitted. These types of problems can arise when the clearinghouse doesn’t recognize the payer. Many smaller insurance companies don’t accept electronic payments and the claim will be returned, necessitating submission of a paper reimbursement request.
Clearinghouse is responsible for matching payer identification numbers with the right claim, a process that tells the organization where to direct the reimbursement request. The practice’s billing and coding specialist must include the correct payer ID number on the claim or it will be returned to the medical provider, further delaying reimbursement.
Reports and Records
Medical clearinghouse maintains a record of each claim that goes through the facility’s system and generates a status report.
The record can be accessed by the practice and used to monitor the location of the claim, where it was sent and when. Sometimes a claim may seem to disappear. Billers can check their batch report against those generated by the clearinghouse to discover what happened to it.
Clearinghouse provides clinicians with a single location to manage all their reimbursement claims and to do so electronically for speedier payment.
Multiple claims can be submitted at the same time and clearinghouse reports allow clinics to track and monitor the status of any claim 24/7.
Practitioners that contract with clearinghouse have the advantage of fewer rejected and denied claims and quicker reimbursements.
Of all the government-run insurance plans, Medicare is the largest and is comprised of four types of coverage, Part A, B, C and D.
Participation is mandatory for some portions and voluntary for others, leading to confusion for patients.
Congress dictates how Medicare claims are paid. Reimbursement requests must be submitted within a specified time frame and the agency prefers to pay providers via electronic fund transfer.
It’s critical for practitioners to verify which Medicare elements a client participates in before services are rendered.
Medicare Part A
The first part of Medicare coverage pays for inpatient care in hospitals, skilled nursing facilities, home healthcare and hospice, but an overnight stay in a hospital is no guarantee of payment. Clients must meet specific requirements for Medicare to pay for inpatient services.
Medicare Part B
The B portion of Medicare coverage is designed to pay for services, treatments and procedures that are medically necessary. Included are services by physicians, home health services, durable medical equipment and outpatient visits. Some preventative measures are covered, including vaccines.
Part B is optional, but those who don’t enroll according to government guidelines are penalized. Patients often believe they’re automatically enrolled when they retire and are dismayed to discover they have no coverage. Recipients also have an annual deductible and pay a 20 percent copay for services.
Medicare Part C
Part C, also known as Medicare Advantage, is an insurance replacement plan offered by private companies that have been Medicare approved. Part C is favored by individuals who prefer private insurance coverage. Depending on the provider, plans can require beneficiaries to pay out-of-pocket expenses, obtain referrals, and only see network providers.
Replacement plans can be used to cover Part A and B services, and some plans include medication and vision coverage. To avoid medical billing reimbursement difficulties and appeals, always verify the client’s coverage, restrictions and limitations prior to treatment, along with the plan’s fee schedule to determine if it differs from Medicare standards.
Medicare Part D
The Medicare prescription drug plan is Part D. While Part D coverage doesn’t typically cause a problem for medical professionals, a large number of Part D recipients mistakenly believe they’ve enrolled in a Medicare supplement policy. Practitioners may find they’re spending a significant amount of time explaining the difference to their patients.
Medicare Supplement Plans
Patients can enroll in a Medicare supplement program, also known as Medigap plans, to cover the costs that Medicare doesn’t pay. It provides a source of secondary coverage, but doesn’t include any non-approved Medicare expenses. Always verify secondary coverage prior to any patient encounter.
More than 50 million people age 65 or older and younger individuals with disabilities have some type of Medicare coverage.
It represents a large population of patients upon which practitioners can draw that are covered by a reliable payer.
Incentive payments may also be available for clinicians practicing in geographic areas with a demonstrated shortage of medical professionals.
As insurance companies scrutinize reimbursement submissions more closely, clinicians are enduring longer turnaround times to collect money on claims.
The simple installation of an integrated EMR can transform those extended waits for funds into a low-delay reimbursement system and Nitin Chhoda explains it here, in this article.
EMRs enable faster reimbursements and can detect claims with potential problems before they’re submitted, virtually eliminating denials.
The majority of denials and contestations can be traced to simple human errors in data entry and by preventable problems that can be avoided by verifying a client’s insurance coverage before services are rendered.
An integrated electronic medical record submits claims electronically to arrive almost instantaneously at the intended destination and can detect an extensive array of errors and notify practitioners prior to submission.
Human Data Entry Mistakes an EMR Can Help Avoid
Mismatched, incorrect procedure codes and improper patient information that doesn’t reflect the information for the client’s complaint is a common cause of denials. An example would be listing a procedure for a male when the client is female.
Each insurance provider has its own set of rules for reimbursement submissions. That includes specific claim forms. An infraction results in an automatic denial until the correct forms are submitted.
Health insurance providers are requesting prior authorization for an increasing number of treatments and procedures. If the clinic fails to obtain authorization, the insurance company can refuse to pay clinicians anything.
It happens infrequently, but a patient may need to see their healthcare professional twice in the same day to receive the same or similar treatments. Practitioners encounter difficulties when submitting these types of claims. Insurance companies view this as a duplicate reimbursement request and will reject it automatically.
It would seem like common sense, but clinicians who don’t file reimbursement claims in a timely manner will forfeit payment. Practitioners have one year to file their claim and such oversights can cost clinics thousands of dollars.
Check the Facts Before Treatment Begins
In a time of high unemployment and loss of benefits, it’s essential for practices to verify insurance coverage and client information before the patient ever reaches the clinic. An EMR provides the means to accomplish these and other tasks with alacrity, reimbursement claims included.
Insurance coverage that has lapsed, been terminated, wasn’t in force when the patient received services, and clients not eligible for coverage represent a major reimbursement problem for practitioners. All of that information can be ascertained easily prior to the patient’s appointment.
Many healthcare insurance providers are offering basic or minimal services and few patients understand their coverage or limitations. It’s imperative that clinicians determine the type of treatments covered under each insurance plan.
What constitutes a reasonable fee for practitioners and insurance companies varies widely. Each insurer has its own guidelines on the amount that can be reimbursed for specific treatments and reimbursement claims that exceed which will be rejected for unreasonable fees.
Clinicians and insurers also differ on procedures. Ordering a CT scan instead of a less expensive x-ray can result in a determination of not medically necessary by the insurance company and loss of income for the practitioner.
An EMR represents the best solution for a low-delay reimbursement system. It has the tools to identify an extensive array of human errors that will delay or prevent claim payments.
An integrated EMR is the key to verifying patient information and insurance coverage to ensure practitioners receive the reimbursement to which they’re entitled.