Increasingly, practices face pressure to increase and optimize revenue. However, some practices have a great landscape that allows them to maximize their efforts to improve their reimbursements and enhance their efforts to provide better patient care.
Behavioral Health practices have a great opportunity to grow in the upcoming years. According to a Market Research Report by Fortune Business Insights, the U.S. behavioral health market size is expecting strong growth of $99.40 billion by 2028.
The 2022 State of Mental Health in America states that over half of adults with a mental illness do not receive treatment, totaling over 27 million adults in the U.S. who are going untreated. People in need of mental health services are growing at a remarkable rate. This sets an opportunity for Behavioral Health practices to offer their services to patients who need them while maximizing their revenue efforts.
In-person patient visits are the primary way that physicians see their patients. However, there are other modalities that practices can implement to attend patients and cater to their needs, such as:
According to a U.S Health & Human Services study, Telebehavioral health may be one of the more successful technologies across the spectrum of clinical services, as outcomes and patient acceptance for Telebehavioral health are comparable to in-person visits. Telehealth allows you to define the right approach to prioritize appointments, maximize your efforts, and care for more patients.
It also enables medical professionals to spend more time focusing on their patients in a higher capacity while alleviating some of the burden and time management on the patient side. Read more about how you can optimize your telemedicine appointments on our blog.
Also, Behavioral Practices implementing Remote Patient Monitoring (RPM) can help them improve patient outcomes, monitor patients continuously, and add a new revenue source.
According to a Goldman Sachs report, RPM is estimated to have the potential to save the healthcare industry $200 billion a year. This type of care delivery allows the transition from episodic care to preventative care.
With RPM, your Behavioral Health practice can detect vital sign changes signaling early mental health episodes or medication interactions and side effects. Read more about it on the blog Implement RPM with Behavioral Health Patients to Improve Patient Care & Add a New Revenue Source
Currently, there is more demand for Behavioral Health services than supply. The challenge is getting the proper demand (patients) to your practice. Practices must have an effective plan to attract patients who match the type and quality of care provided.
Some tips you can follow to achieve this are:
Changes in reimbursement affect patients´ ability to seek treatment and providers´ ability to provide services. Billing claims are increasingly complex, which can easily drive-up denials and rejected claims. An important initiative is eliminating insufficient insurance payments and establishing a system to maintain consistent income.
As an initial step, practices must ensure clean claims are filed when first submitted. The claim needs to include all necessary information upon receipt. Secondly, claims that are denied must be followed up quickly. If there´s a pattern of denials, it often pays to schedule a call or meeting with the payer to review them.
A focus on clean claims and rapid response to denials will also lead to more efficient billing processes, therefore, better cash flow and faster reimbursement return. Fixing these billing errors can help you reduce denials and get paid for your work.
To learn more about how you can increase revenue in your Behavioral Health practice, get in touch with an AdvantEdge expert, or stay up to date on company and industry trends by visiting our Linkedin page.
September is Healthy Aging Month, a designation that started in 1992. It is a time to spread the message that it is possible to adopt a healthier lifestyle at any age and mature gracefully.
People celebrate this month by incorporating habits like exercise, eating healthy food, and getting enough sleep into their daily routines. It is also a time for encouraging others to stay active and take steps to improve physical and mental health.
According to U.S. Census Bureau data, by 2030, adults aged 65 and older are projected to outnumber children for the first time in U.S. history. In that year, all boomers will be older than 65 and they will make up 21% of the population, up from 15% today.
By 2060, nearly one in four Americans will be 65 years and older, the number of 85-plus will triple, and the country will add a half million centenarians. With this number of older adults, the country could see greater demands for healthcare, in-home caregiving and assisted living facilities.
Healthcare services should adapt to this population needs and promote healthy aging to improve quality of life. Medical practices can help promote healthy aging in the population while still increasing revenue.
Increase early assessment and diagnosis, risk reduction, prevention, and management of chronic diseases for people with or at risk of certain conditions.
Every patient can go once a year without any medical symptoms for a routine check-up and preventative care. Insurance companies are required to pay for these annual check-ups for all their subscribers without applying deductibles or copayments. Insurance covers 100% of the allowed amount.
Investigate how many of your patients have not set an appointment for that regular check-out in the last year. This is good for your older patients because they can find something that could save their lives. It is also good for the providers because they will have extra revenue that is covered entirely by the insurance company.
Clinical preventative services can prevent disease or find it early when treatment is more effective. These services can include:
Remote Patient Monitoring (RPM) can help you detect symptoms or other signs that might be related to your patient´s illness. This will allow you to take better care of your elderly patients with chronic conditions.
RPM works as an extension to your practice that can help you monitor your patients continuously, improve patient outcomes, grow your practice profitability and more. This care system delivery is estimated to have the potential to save the healthcare industry $200 billion a year and allows the opportunity to transition from episodic care to preventative care.
Also, offering Chronic Care Management (CCM) to your elderly patients who experience chronic illnesses can help you get added revenue for your practice in your existing patient population. It can also elevate care for patients by engaging in their care plans, managing medications, adding support at home, and more.
Stay in constant contact with your elderly patients to develop a close relationship with them, improve patient care and engage them with your practice to increase loyalty.
Telemedicine has advanced from a curious form of clinical communication to a mainstay in the way providers and consumers interact. According to the American Telemedicine Association (ATA), some of the telemedicine benefits are:
Offering telemedicine to your elderly patients can help you monitor their health remotely and it can give them the option to take care of their health while at home. Some elders might struggle with getting to your practice facility due to disabilities or movement impairments.
Consider giving them this option and meet up with their relatives to make sure they set up everything correctly so patients in advanced age can take advantage of these services. Read more about how to optimize your telemedicine appointments on our blog 5 Tips to Optimize your Telemedicine Appointments
To learn more about how promoting health aging can help you improve patient care and increase revenue, get in touch with an AdvantEdge expert, or stay up to date on company and industry trends by visiting our Linkedin page.
The House passed the Inflation Reduction Act (IRA) in August. IRA is a sweeping climate, health care and tax package that includes major reforms on drug prices and extends boosted Affordable Care Act (ACA) subsidies through 2025.
President Biden signed the Inflation Reduction Act (IRA) into law on August 16, 2022. According to the White House statement, “the Inflation Reduction Act will lower costs for families, combat the climate crisis, reduce the deficit, and finally ask the largest corporations to pay their fair share.”
Regarding healthcare, the law focuses on cutting prescription drug costs, lowering health care costs for Americans, and defeating special interests.
This law allows the federal government to negotiate prices for a small subset of Part D and Part B drugs. Before IRA, the U.S government was explicitly prohibited from engaging in price negotiations with drugmakers on behalf of the Medicare population.
Starting in 2026, Medicare will begin negotiating the price of 10 drugs, followed by an additional 15 drugs in 2027. Then eventually 15 more drugs in 2027, and an additional 20 drugs in 2029 and beyond. The list of the first 10 drugs selected for negotiation is expected to be made public in 2023.
According to a Fierce Healthcare news, experts say regulating the bill will have a significant impact on providers, including those that rely heavily on reimbursements for Medicare Part B drugs. To address this, there will be a need for providers to purchase drug at the negotiated rate as opposed to market prices.
The White House states that with this law 3 million more Americans will have health insurance and that with the law, 5-7 million Medicare beneficiaries could see their prescription drug costs go down due to the prescription allowing Medicare to negotiate prescription drug costs.
It adds that 50 million Americans with Medicare Part D will have the peace of mind knowing their costs at the pharmacy are capped at $2,000 per year, benefiting about 1.4 million beneficiaries per year.
On August 1, 2022, the Centers for Medicare & Medicaid Services (CMS) issued the Fiscal Year (FY) 2023 Medicare Hospital Inpatient Prospective Payment System (IPPS) final rule.
This policy updates Medicare fee-for-service payment rates and policies for inpatient hospitals for FY 2023, as required. The final rule updated the IPPS rates by 2.6% in FY 2023 compared to FY 2022.
The increase reflects a 4.1% market base update, less 0.3 percentage point for productivity, plus 0.5 percentage point required by statute.
The American Hospital Association (AHA) thanked the CMS for deciding increased inpatient payments next year rather than the cut they proposed. However, according to Stacey Hughes, AHA´s Executive Vice President, on a statement,
“This update still falls short of what hospitals and health systems need to continue to overcome the many challenges that threaten their ability to care for patients and provide essential services for their communities.”
Due to the impact of COVID-19 PHE (Public Health Emergency) on measure data used in the Hospital VBP (Value Based Payment) Program and HAC (Hospital Acquired Condition) Reduction Program, the CMS will be finalizing its proposals to suppress several measures in both programs for purposes of FY 2023 scoring and payment adjustments.
In the healthcare industry, there are plenty of business intelligence platforms that can help you keep the pulse of your medical practice, identify areas of improvement, and provide you with insights to make data-driven decisions.
However, a good BI platform can be sometimes hard to find. With typical BI platforms, the process to see your metrics and how your practice is doing is usually more manual.
Your Key Performance Indicators (KPIs) are not seen at a glance, and you are left doing all the hard work – figuring out what to measure yourself against, researching the industry standards, and benchmarking your practice against broad indicators that the industry holds.
Doing all these tasks on your practice takes a lengthy and exhausting process leaving you with this administrative burden. However, with a robust Business Intelligence (BI) platform, you will be able to reduce costs, increase your revenue, and improve patient satisfaction by detecting areas of improvement.
Your BI platform should be able to show you KPIs and areas of improvement you need to focus on. With this information you may be able to get back to your billing team with some valuable information about your practice’s health. Effectively deployed, these metrics can help you see very quickly how you are doing. Are you meeting your targets? Are you better off now compared to last year? How has COVID-19 impacted your financial health?
This quality can help you understand your medical practice trends and story. Why have your days in A/R increased? Which denials are creeping up and from which payers? What is the effect of no-show patients on your practice revenue? An effective BI platform will allow you to dive deep into the reasons behind each indicator, understand which metrics are fluctuating and why so you can set up a plan of action to improve those metrics.
Working with an efficient team who keeps an eye on your practice is as important as having access to a good platform in the first place.
If you don’t have a solid structure on the backend working your denials, your no responses, looking at your over 90-day A/R, trending out your denials and rejections, and focusing on areas of improvement, that is not good business intelligence.
As an AdvantEdge client, your practice will have complete visibility into all financial activity associated with your business. AdvantEdge Analytics (A2), web portal provides your practice with 24/7 “anytime-anywhere” access to data and information that allows you to manage your business and measure your performance.
A2 data is updated daily providing you with drill-down access to detailed information by payor, provider, location, modality, etc.
AdvantEdge not only offers one, but two Business Intelligence platforms to help you monitor the pulse of your practice. Besides AdvantEdge Analytics (A2), we offer a second powerful analytics tool Datalytics, which allows access to the patient level details for stakeholders with appropriate security.
This platform also allows you to understand your no-show rates and the economic benefit of one additional patient appointment per day for your practice.
If you want to learn more about how to reduce costs, improve your medical practice and increase revenue by using a good BI platform, contact an AdvantEdge expert and stay up to date on company and industry trends by visiting our LinkedIn page.
Communication is an important process in every business, including medical practices. Having effective communication with your medical billing company is essential to identify areas of improvement, streamline your processes, and increase revenue.
Effective communication affects processes, efficiency, and every layer of your practice. This important process of sharing information between your business and your billing partner is essential to reach your organizational goals.
First, it is important to communicate to your medical billing company what you are looking for by partnering with them. Set your expectations and let them know what you expect to achieve with this partnership. Your billing company will provide you with best practices and industry expertise. They will also be able to help you identify areas of opportunity to set your practice for success.
Here are three reasons why having effective communication with your billing company is essential for your practice:
Physician practices are more successful when there is regular communication and collaboration with their medical billing partner. At AdvantEdge (AHS) we have numerous communication methods for practice performance and strategic direction, as well as day-to day management of the revenue cycle.
Your AHS Client Manager will be actively engaged backed by a full, support team to drive the value that you deserve for the service you are contracting. Our Client Managers are in frequent communication to address concerns our clients have on an ongoing basis to monitor trends, identify areas of improvement, and optimize revenue.
To learn more about how to optimize your communication with your billing company, get in touch with an AdvantEdge expert, or stay up to date on company and industry trends by visiting our Linkedin page.
The telemedicine market is expected to hit $324.38 billion by 2030, according to a new report from Growth Plus Reports.
Telemedicine has experienced a swift growth in the market in recent years and it is forecasted that it will continue growing. The significant contribution to the growth of this market is attributed to the COVID-19 pandemic and more government programs designed to support this type of healthcare delivery.
The adoption of this branch of e-health helps to bridge the gap between patients and physicians while allowing physicians to take better care of patients even remotely. Additionally, it can support healthier and higher revenues by enabling medical professionals to attend more patients.
Read more about telemedicine and how you can improve the way you deliver care with telemedicine on our blog 5 Tips to Optimize your Telemedicine Appointments.
Telemedicine has gone from being a side feature of the healthcare system to an expectation. The future of this healthcare delivery system looks bright.
Physicians and other medical professionals can see this as an opportunity for their practices to implement telemedicine, if they haven´t done it, and optimize their telemedicine approach to improve patient care, prioritize appointments, and increase revenue.
Read more in our article Telehealth Services Explode, Making a Case for Hybrid Health Care (ahsrcm.com)
CMS (Centers for Medicare & Medicaid Services) issued the Calendar Year (CY) 2023 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System.
This proposed rule describes the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and the ASC payment system. CMS is proposing to update OPPS and ASC payment rates for CY 2023 by 2.7%.
These updates are based on the projected hospital market basket percentage increase of 3.1% reduced by 0.4% point for the productivity adjustment.
Based on the proposed policies, CMS estimates that total payments to OPPS and ASC providers for CY 2023 will be approximately $86.2 billion and $5.4 billion, respectively. These total payments include beneficiary cost-sharing and estimated changes in enrollment, utilization, and case-mix.
This represents an increase of approximately $6.2 billion and an increase of $130 million, respectively, from CY 2022 payment amounts.
Also, this CMS rule proposes to update and refine the requirements for:
The document also proposes updates to the requirements for organ acquisition, rural emergency hospitals, prior authorization, and overall hospital quality star rating.
Read more about this proposed outpatient prospective payment rule on this CMS fact sheet. CMS encourages stakeholders to review the rule and submit formal comments on the rule by September 13, 2022.
There are many complex regulations and steps involved when it comes to pathology billing and coding. Mistakes can occur at many points of your “front-end” and “back-end” processes. This can reduce collections and increase days in A/R, delay reimbursement and lead to compliance violations or fines.
In today´s era of ongoing pressures on pathology reimbursement, finding and fixing mistakes in your billing process is more important than ever. Some of the most common errors pathology practices face are unbilled tests, eligibility errors, underpayments, and documentation gaps.
With the high volume of tests in a typical laboratory, it is very easy for tests to not be billed. The first control process that needs to be in place is accession reconciliation. Your billing system should identify missing accessions based on sequence numbers or a comparison with LIS or other lab reports.
Most billing systems interface with LIS, ADT, and other electronic systems, which drastically reduced the error rate versus paper. However, electronic interfaces require careful management of exceptions, such as records that are rejected.
If your practices´ charge information is on the LIS, make sure it matches with demographics from your ADT or EMR system. If not managed carefully, this matching process can result in tests not billed. This coupled with the high error rate in demographics means that there are always exceptions.
Managing these exceptions every day and assuring that they are resolved is essential to prevent lost revenue.
Eligibility errors are one of the main reasons behind denials. The pathology group leadership and their billing experts (internal or outsourced) should meet with administration to review and discuss eligibility denial results. Suggesting improvements to the processes, such as online eligibility checks, verification of insurance information at discharge, etc. can be well received.
For patients presenting for a lab test, the front-end process is somewhat easier to address to reduce eligibility errors. Have an online eligibility check at the time a test is ordered. Also, having the eligibility information readily at hand also means that the co-pay and, perhaps, deductible can be collected prior to the test.
There are some cases where the patient is simply not covered. Where possible, labs should identify and address these situations prior to performing the test. Also, don´t underestimate the need for patient education: they may not know which tests are covered by their insurance and many on high deductible plans bought them for the low premium.
One of the main sources of missed revenue are claim denials. Therefore, each one needs to be worked, ideally by automatically routing to the right specialist; then tracking to assure it is worked on a timely basis.
More subtle, but often a source of substantial revenue, are underpayments of various types. This can happen when a payer remits the incorrect amount. It is essential that your lab has a good handle on expected payment amounts. The only way to catch these errors is to have the expected amount programmed into your billing system or by doing a regular payment analysis.
An important related consideration is the fee schedule. If it´s out of date, you may be filling claims below some payers allowed amounts. Or you may have newer tests without a fee established. Plus having the proper fee schedule is always useful during payer negotiations.
Correct coding is essential for insurers to accept claims and pay pathologists correctly and in a way that minimizes downstream denials.
Practices and departments should be getting feedback from their internal coding team or outsourced partner on error rates by physician to highlight areas of improvement. Physician training is often very productive. Pathology practices´ leadership need to stress the importance of accurate reports.
Due to the evolution of coding and payment mechanisms, documentation improvement processes are even more critical. Coders must have an excellent level of detail for accurate coding. It is more efficient to have the information included in the first report to avoid any need for clarification and addenda.
If you want to learn more about how to improve your pathology billing, download our Pathology Billing Tip Sheet white paper. Get in touch with an AdvantEdge expert and stay up to date on company and industry trends by visiting our LinkedIn page.
The healthcare industry is clearly evolving, making telehealth, telemedicine, and remote patient care more significant components of care delivery.
Telemedicine in particular has advanced from a curious form of clinical communication to a mainstay in the way providers and consumers interact. It has gone from being a side feature of the healthcare system to an expectation.
According to the American Telemedicine Association (ATA), some of the telemedicine benefits are:
Defining the right appointment approach for your patients can help you prioritize appointments. Some patient issues can be treated with a brief phone call or a telemedicine visit. This approach ensures patients needing the highest level of care have better access to same-day appointments if necessary, and practice profitability is maximized.
Read more about this on our article Telehealth Services Explode, Making a Case for Hybrid Health Care
Telemedicine enables medical professionals to spend more time focusing on their patients in a higher capacity while alleviating some of the burden and time management on the patient side. Additionally, it can support healthier and higher revenues by enabling medical professionals to attend to more patients.
Therefore, here are five tips to optimize telemedicine appointments:
Be familiar with the equipment and technology you will be using. It is important to have a better understanding of how the system works, including how to troubleshoot common problems. Remember to have alternate options to reach the patient (phone, email, or text) in case something goes down. Additionally, the environmental component is as essential as the technical one. Make sure you have good lighting, minimize background noise, and confirm the patient can hear and see you well.
Obtain an informed consent form from your patient before the session. Assess the patient’s familiarity with telemedicine and provide orientation (such as benefits, and security measures involved) as needed before the virtual encounter. You can consider giving a telemedicine checklist to help your patients better understand the process, set expectations, and prepare appropriately on their end.
Have all the documentation you need ready. Remember to have your patient´s previous visit notes on hand. This will help you in case you need to refer to a patient´s previous note during a session for proper diagnosis. Also, it is important that you stay on top of any insurance policy changes regarding telemedicine. Regularly check with your payers to ensure your patients are still covered.
Just like in your face-to-face visits, patients will still need to pay for their co-pays after the telemedicine visit is done. Enlist a good payment processor that integrates with your patient portal, your website, or your practice management software (PMS). This will make things easier for your patient and help you collect your payments for these encounters faster.
Communication is the number one factor influencing the patient experience. Even if it’s a virtual encounter and not an in-person one, it´s important to create an engaging and safe environment for the patient. Remember to maintain eye contact. If you need to look away, explain them what you are doing so to assume them that you are still paying attention. Maintaining consistent eye contact creates a positive and meaningful experience for the patient.
Technology is constantly evolving, and the way you and your medical practice deliver patient care should evolve as well. Those that adapt to these changes are set to see significant clinical and financial improvements.
To learn more about best practices and how to optimize your telemedicine appointments to increase revenue and improve patient care, get in touch with an AdvantEdge expert, or stay up to date on company and industry trends by visiting our Linkedin page.
Even with loosening restrictions and mask mandates amid the COVID-19 pandemic, a recent report based on data from the Forbes Health-Opsos Monthly Health Tracker has found that nearly one-third of adults are using remote health services more now than before the pandemic. Of that group, 19% of respondents indicated they have increased their telehealth or doctor visits, while another 10% say they used telemedicine websites or apps more frequently.
The pandemic saw a large uptick in remote health services, and it has only increased since then. Based on a previous post that AdvantEdge published back in September 2021 tracking the telehealth trend, the CDC found that in June 2020, “telehealth visits represented over 35% of all visits in June of that month and that ‘telehealth visits declined as the number of new COVID-19 cases decreased but plateaued as the number of cases increased.’”
According to this recent Forbes data, the telehealth trend may be on the upswing for quite some time, given the relatively low number of cases, and that telehealth visits and the cases are no longer linked.
As a result of the increased utilization of telehealth services, more health insurance providers are including these services as part of their care. Additionally, according to an American Psychiatric Association finding, in 2021 nearly six in 10 adults said they would use telehealth for mental health care – up 10% from 2020.
The healthcare industry is already investigating what a hybrid model – inpatient care and telehealth services – will look like. According to an interview between Healthcare IT News and Mike Brandofino, CEO of Caregility, a vendor of telehealth technology and services, these two are poised for symbiotic growth:
“Telehealth – when adopted as an enterprise-wide strategy – elicits many creative uses. We have heard from doctors who say that, thanks to virtual rounding, they get more done and see more patients by not having to walk miles through hospital hallways.”
Other examples include virtual care in patients’ homes and assisted living communities. Regardless of “how,” there has been a growing interest in enhancing the entire care experience through the adoption of hybrid care models that include both in-person visits and virtual encounters.
Read the full article for more information – “How telehealth can help inpatient care, and what a hybrid future looks like.”
The future of telehealth looks bright – it will enable medical professionals to spend more time focusing on their patients in a higher capacity while alleviating some of the burden and time management on the patient side. Additionally, it can support healthier and higher revenues by enabling medical professionals to “see” more patients.
Modern America has made a concentrated effort in bringing to light the need for mental health services while at the same time trying to de-stigmatize this type of care, though a recent report indicates we still have some ways to go.
According to results from a recent online survey from the National Council for Mental Wellbeing, there is a considerable gap between the number of Americans that need care for depression, anxiety, and other mental health conditions and those that can receive it.
According to the data, 42% of U.S. adults could not get the mental health care they needed in the previous 12 months due to cost and other barriers. Substance abuse service needs also accounted for one-quarter of the responses.
According to Chuck Ingoglia, CEO of the National Council for Mental Wellbeing, these findings aren’t surprising. He states: “We’re in an environment where there is increased attention to these issues at the federal level and state level, there have been efforts to require insurance companies to provide adequate coverage for behavioral health conditions, and yet it still is a challenge for individuals, and that’s a real shame.”
The nationwide survey – Access to Care – was conducted in May by The Harris Poll and included 2,052 Americans. The primary barriers included availability, cost, lack of diversity, wait times, and proximity to care.
Additional insights garnered from the survey indicate that access to mental health services will only worsen without intervention. Nearly 40% of participants noted that expenses had prevented them from getting care, whether it was out-of-pocket or through insurance. Additionally, 28% of respondents stated finding care was difficult, and it is believed that COVID-19 played a hand in upending a lot of these services due to provider shortages and the Great Resignation.
Many of these issues – such as inadequate care and barriers to access – have been a known, ongoing issue.
Improvements need to be made in behavioral health, especially for older adults. According to StatePoint Media, behavioral health disorders affect one in five adults over 55. Dementia is the most common behavioral health disorder, with experts projecting that more than 9 million Americans age 65 or older will have this condition by 2030. Additionally, due to mental health disorders, older men have the highest suicide rate of any age group or gender. Among men who are 75 and older, the suicide rate is 40.2 per 100,000 – almost triple the overall rate.
For information on self-care tips on how older adults can deal with behavioral issues, read “Behavioral health pointers for older adults.”
Given today’s climate, and the pressures of healthcare practices collecting on their fees, physician groups and professionals need to know how to effectively evaluate a billing company. Declining reimbursements, increased costs from complex regulations, and higher employee costs are just a few of the reasons why these groups should consider hiring a billing service or replacing their current one.
Here are three considerations to effectively evaluate a billing company:
1. Performance vs. Price
Billing services tend to reflect “you get what you pay for.” It’s easy to set up and operate a billing company that can handle simple tasks, but it’s a different thing altogether when looking for a highly optimized service that can achieve high levels of net collections, consistently. If a practice just focuses on the price, many factors – denial management, A/R management, patient payments – may be overlooked, directly impacting the practice’s revenue.
Therefore, it’s imperative for practices to look at both performance and price to determine its best interests. Companies might be able to find a low-cost service, but that usually means they have less investment in technology, training, and repeatable processes. To make sure you are collecting all the fees that are owed to you, you need to consider performance as a key driver in your decision-making.
2. Reporting and Dashboards
Another avenue to explore to effectively evaluate a billing company is reporting and dashboards. A few years ago, access to real-time data and information gave companies and practices a competitive advantage; now it’s standard just to stay in business. Today’s leading companies offer their clients robust advanced analytical reporting and “dashboards” showing practice performance at a glance plus the ability to drill down into details as needed. It’s important to ask to see the billing company’s standard monthly reporting package.
Along with “charges, adjustments, and payments,” these reports should also include summaries by payer, by location, and by physician. Additionally, being able to receive customized reports, and in the formats you need them in, would be ideal. Be sure you’re able to visualize the most important elements of your billing practices so that your practice can maximize its reimbursements.
A final way to effectively evaluate a billing company is to see how advanced their technology offerings are. Technology is what enables real-time data, so the incorporation and investment of emerging technologies like artificial intelligence (AI) and machine learning (ML) should be included in your billing company’s offerings.
You can read about the importance of AI in medical billing by reading our white paper, “Why AI Technologies Are Essential for Your Medical Billing.”
Given the constantly changing regulations and complexities within the industry, technology is imperative. It’s a huge advantage to deal with a company that has its own proprietary software and IT resources. Remaining independent of third-party services enables your practice to receive customized features, interfaces, implementations, and increases time management. Of course, the billing technology used by a billing company must be robust. The company should be experienced with front-end interfaces of all types, whether from a hospital ADT or ECC system, RIS, PACS, LIS, or EMR. Finally, make sure that they will be responsible for quickly and seamlessly integrating their technology into your current stack. Your business can’t afford any downtime, as that will directly impact on your revenue collection.
To learn more about best practices and how to evaluate a billing company, check out our “How to Evaluate a Billing Company” white paper, get in touch with an AdvantEdge expert, or stay up to date on company and industry trends by visiting our Linkedin page.
Being able to improve radiology billing is a priority for every practice to help maximize reimbursements, however, it gets more difficult every day for several reasons – insurance companies change their rules and parameters, patient costs and co-payments continue to rise, growing audits, etc.
With this in mind, here are 3 tips to help you improve your radiology billing:
It’s critical that office-based practices collect and verify patient demographics, including name, address, phone, social security number, insurance, guarantor, etc. every chance they get. To that extent, it’s important to effectively train employees to ask questions like:
An effective way to drill on the importance of collecting this information is to illustrate how much extra work is needed if any of the information is incorrect.
For hospital-based practices, scheduling periodic meetings with hospital executives is a good rule of thumb for capturing the demographics and making sure the data is complete.
Whether office or hospital-based, if technology is in place, insist on eligibility checking as early into the process as possible. Offices should do this after scheduling in order to see the patient status. Hospitals should perform these checks after registration.
Another way to improve radiology billing is to keep a close eye on the denials rate. While most claims are paid the first time they are filed, some are not – and that percentage can be a problem. By monitoring the denials rate, (or “first pass denial rate”), this indicates how effective a practice’s upfront process is and how well its billing edits and checks are performing.
As denials occur, it’s important to have processes in place for resolving them and submitting an appeal. Unfortunately, it’s frequent practice for billing staff to refile the claim, but this is not an effective process. Having this process in place is what separates good billing results from mediocre. A second denial measure is used to monitor the percentage of charges that are denied and never paid (percentage should be in the single digits).
Higher deductible insurance plans and co-pays are on the rise, putting more fiscal responsibility on patients. Not every dollar will be coming from insurance companies, so it’s important to closely monitor how much patients owe while “treating” patients with care. Here are some practical ideas:
Want to learn more about how to improve radiology billing? Download our “3 Tips to Improve Your Billing” white paper, get in touch with an AdvantEdge expert, or stay up to date on company and industry trends by visiting our LinkedIn page.
Now more than ever, maximizing medical billing reimbursement is critical for hospitals, private practices, and medical facilities. With COVID-19 cases still lingering, the widespread medical professional shortage due to the Great Resignation, and the No Surprises Act changing the landscape of patient care, medical billing professionals need to stay current and agile in making sure they are collecting every dollar owed.
Are you collecting every dollar owed? The best way to answer this question is by reviewing historical data (over the past 12 months or so) to determine your net collection rate, but this is very time-consuming and expensive – and pulls your professionals away from critical everyday work.
So let’s discuss some shortcuts that can help you maximize medical billing reimbursement for your practice.
Generally, after conducting an analysis, our AdvantEdge professionals determine that billing operations fall into one of these three categories:
The Definition and Importance of Well-defined Processes
When we talk about a “well-defined process,” we mean that a company has the major elements of an RCM cycle in place such as
For providers in the first category, which unfortunately reflect only a small percentage of how many traditional providers have operated in the past, only minor fine-tuning needs to be made to one or certain areas within their processes.
It’s important that employees not think of their position in a silo (nursing, scheduling, billing), but instead as a functional group. By interacting and communicating as a group, this enables team members to see the big picture and how each person fits in, which ultimately will solve billing inefficiencies.
Prioritize Your Processes
Maximizing medical billing reimbursement should reflect strong attention and dedication to maintaining and promoting these well-defined processes. Have a “this is how we do things around here” so that staff members understand and continually follow best practices. With that said, it’s also important to be open to improvements to the process.
For example, consider the process of a traditional private practice scheduling appointments. Historically, the process has been calling to book and remind patients of their upcoming appointments. However, the employee that handles scheduling has noticed their demographic includes a younger generation of patients that don’t like to talk on the phone, and only interact digitally. By voicing a tweak to create automated text or email notifications requiring a response, the practice could see a higher engagement and confirmation of appointment date/time.
This is a very simple example, but it indicates the attention to process while having the flexibility to make changes that ultimately benefits the practice and its collections.
Do you believe your company might fall into the second or third category? If so, we suggest you download our free eBook, “Are We Really Collecting Every Dollar We Are Entitled To?,” that provides insight into how to revive your processes so that you can achieve the top category.
To learn more about maximizing medical billing reimbursement, we invite you to get in touch with an AdvantEdge expert now, or stay up to date on company and industry trends by visiting our LinkedIn page.
It appears that being able to have a baby in a hospital may be at jeopardy in some locations as soon as next month.
The medical industry – especially hospitals – continues to be impacted by The Great Resignation – with some of the first services to go are birthing units.
AdvantEdge has been following the medical staffing shortage trend for nearly a year now, beginning with an article we published in June 2021 around how the labor shortage is hurting in-house billing operations.
Recent news has indicated that at least five hospitals across three states have begun scaling back services due to staffing shortages.
For example, in Wyoming, Memorial Hospital of Carbon County is ending labor and delivery services on June 15, which is spending more than $100,000 a week bringing in traveling nurses to take the place of a number of staff nurses that have quit. Another hospital in the state, South Lincoln Medical Center, will stop these services as well beginning June 1.
Also in Massachusetts, Beverly Hospital announced in May it will be closing its freestanding birth center in September. This is after the hospital stopped taking new birth center patients in March due to the staffing shortage.
Regarding this announcement, Mark Gendreau, MD, chief medical officer of Beverly Hospital, was quoted saying, “Based on ongoing staffing issues…we have determined that it is no longer possible to sustainably operate this program in the long term.”
Finally, Schenectady-based Ellis Medicine in New York also paused inpatient adolescent mental health services, effective May 2.
Bringing in talent has been a widespread issue since the start of the pandemic, and has gone even further to include professionals quitting their positions for a number of reasons. These are just the latest stories regarding hospital and healthcare worker shortages, and it’s anticipated that hospitals and medical facilities will continue to feel the strain of available workers. It will be interesting to see what other services and medical functions administrators will need to pause or cut to remain solvent.
After more than two years, the consequences of COVID-19 continue to knock on our doors with troubling new data day after day. Just as communities begin to ease their restrictions, another wave crushes the hope of a pandemic-free tomorrow.
Using data as an asset to fight against the virus and protect our communities, the Centers for Disease Control and Prevention (CDC) shares weekly insight and trends based on closely tracked data. In their May 13 release, they shared 9 findings all should consider to stay safe through this uncertainty.
Cases, Hospitalizations, & Death
Although all three of these areas of insight seem interconnected, and for most of this pandemic have been closely related, the data begins to show that they have been moving in divergent paths. This is especially true when comparing cases and hospitalizations to death rates.
In the seven-day averages, the rate of new cases increased 30.7% (from 64,863 to 84,778), and the trend remained consistent when analyzing the number of hospitalizations which experienced a 17.5% increase (from 2,238 to 2,629). The highest daily averages in the past 14 days were experienced in New York: 20 percent (2,755), California: 27 percent (1,725), Florida: 37 percent (1,750), Pennsylvania: 44 percent (1,324), and Texas: 7 percent (1,163). The CDC identified both rises as part of a gradual increase that has occurred over the last five consecutive weeks.
On the other hand, the average death toll has decreased 15.4% (from 322 to 273). But this of course does not take away from the approach of the tragic milestone of 1 million deaths brought by COVID-19.
The leading factor in the decline of infections, hospitalizations, and most importantly deaths is the growing vaccination rate across the United States. Although the CDC identified an 18% fall from the previous week, the overall numbers across the population are on the right path, especially considering the initial skepticism and hesitancy seen from some states and demographics. The U.S. is now at a 77.8% vaccination rate with about 258.3 million people having received at least one dose of the COVID-19 vaccine. Not far behind, the number of individuals who have taken both doses are at 66.3%. The rate of both the initial and secondary vaccine administration experienced an increase from the previous week.
Variants & Testing
As more individuals get tested, we should expect the number of detected variants to continue to rise as it is the natural progression of any virus as it fights to stay alive. The national testing rate has slightly declined in data collected by the CDC that analyzed the reports for the week of April 29, 2022 (down 4.6% from 783,008 to 746,765), yet the rate of individuals testing positive still experienced a rise of 1.98% (now at 9.1%) from the week prior.
A former commissioner of the FDA (Food and Drug Administration), Scott Gottlieb, MD, recently shared his thoughts on testing with CBS News stating, “I think that we’re dramatically undercounting cases” and “we’re probably only picking up one in seven or one in eight infections”. This jump in positivity while having a decreasing testing rate and low probability of accuracy can pose a threat as more individuals are likely infecting others without knowing. This feeds to the continuous cycle of wave after wave, variant after variant.
From the projections made for the week ending May 7, the CDC estimated that the BA.2 omicron subvariant would account for 56.4% of U.S. cases. Making up the other largest group, BA.2.12.1 accounts for 42.6% of cases. Other omicron sub variants account for the remaining cases.
In our third Employee Spotlight of 2022, we talked with Rick Brozovic about how he enjoys all parts of the job—including solving client issues at 3 a.m.
A 31-year health care industry veteran, Rick Brozovic is passionate about his job as Interface Director at AdvantEdge, where he’s been on staff since 2009. He oversees a staff of six, including an employee in Bangalore, India. His team is responsible for all the data that’s loaded and imported into the AdvantEdge system.
“We get file extracts and real time HL7 interfaces from hospitals in the form of demographic information, charges and reports that end up flowing into the interface database,” Rick says. The data is “very well secured and protected. It’s a big responsibility, and we take our jobs very seriously.”
Interestingly, an IT job wasn’t always in the cards for him. A native of Lombard, Illinois, a western suburb of Chicago, early on he thought he wanted to be a writer. “I dabbled in poetry and English literature, and liked authors like Percy Shelley and William Shakespeare,” he says.
However, while a student at Moraine Valley Community College, in Palos Hills, Illinois, he worked part-time at a cabinet factory where he met three other people who also held earlier ambitions to be writers that led them to full-time careers in the factory. That was a pivotal moment, he says. “I changed gears and learned computer science instead”.
Trading Books for Binary and Bits
After college, he joined Oberweis Securities, overseeing their Information Systems (IS) Department. From there he moved on to Tech Support and Development at System Software Associates in Chicago, Illinois – at the time the largest IBM midrange software company in the world.
Rick joined AdvantEdge through its acquisition of Physicians’ Service Center, where he was Director of IS. He led the migration of PSC’s medical billing database to a new software platform under AdvantEdge. Rick’s team was responsible for implementing Virtual Manager enhancements that originated from Lombard’s legacy system – things like specialized interfaces with a Robo-Calling vendor, automated Skip Tracing, Denial Management Reporting, and enhancements to the interface import engine. A few years after joining the Virtual Manager Development team, the Chief Information Officer at the time; Manny DaSilva, asked if he could take over Virtual Manager interfaces.
One of his favorite parts of the job is working with all the groups from AdvantEdge Operations, Client Management, and clients. “I’m a competitive person and I want to see the company succeed. Working with interfaces, the value to the company and our clients is very evident and it’s easy to see the fruits of our labor.”
Overcoming any issues that might arise from data formatting issues or setting up new clients just comes with the territory. “It’s two sides of the coin,” he says. “If something goes wrong at 3 a.m. in the morning on Sunday, we must act quickly to solve an issue such as one that could affect a client’s ability to bill. We have to get them up and running as quickly as possible.”
At the same time, he says, “It’s a very exciting job to be a part of. There’s always a lot going on.”
Rick isn’t always working. He recently relocated to Tulsa, Oklahoma, where he enjoys spending his free time with his two grandchildren. He also enjoys reading at least one or two books per month, and is actively involved in his church.
We’re four months into the No Surprises Act, which is best known for its payment transparency for patients. However, putting these regulations into practice – particularly providing good-faith estimates – is already a nightmare, states a number of compliance experts.
It’s well known that the healthcare industry is full of complex regulations, and Surprise Billing just makes things more “daunting” for healthcare providers, states experts.
Praised for tackling one of the primary issues for patients – being stuck with unexpected, usually high medical bills because they may have been unknowingly cared for by a medical professional that was out-of-network – the other side of the coin will leave medical professionals and compliance professionals hustling to remain in compliance with this new legislation.
Harvey Rochman, a Manatt professional services firm partner, has compared the No Surprises Act to a “small Affordable Care Act (ACA)” because there are a variety of lesser-known requirements of the bill that might come as a shock or will be extremely difficult to put in place.
Rochman continues, “If you had to single out one thing that is really the most complex and difficult…it’s the good-faith estimate.” According to the bill, a broad range of providers will be required to provide these estimates to its patients. For example, dermatologists, who don’t provide emergency services at hospitals, will be subject to provide good-faith estimates.
Additionally, providers will be under strict time constraints to provide these good-faith estimates to patients. In some cases, it might be one day after the procedure is scheduled. In other situations, providers will have three days to provide the estimate within 10 days of scheduling the procedure.
There’s also the issue of determining who the “convening provider” will be to provide the estimate – is it the hospital or the specific surgeon? The AHA drafted a letter to the CMS stating that putting these measures in place have been difficult for even the most seasoned and sophisticated hospitals; it’s extremely difficult to automate, and many estimates need to be tailored to each patient.
As we’re in the early stages of the No Surprises Act, compliance will continue to be an uphill battle for providers and hospitals, and will be very costly to those that are unable to achieve compliance. This is a developing story that AdvantEdge will be keeping a close eye on.
To learn more, connect with us on our LinkedIn page or contact us to speak with an AdvantEdge expert regarding your billing needs. Additionally, stay up-to-date on company and industry news by subscribing to our newsletter.
Minimizing anesthesiology denials (as well as denials for every specialty) is a constant goal for every billing professional. The unfortunate reality is that denials are a part of everyday life, and only add more complexity to a regulatory and compliance-heavy industry.
However, with proper workflows and processes in place, professionals can more quickly and efficiently resolve denials that directly impact cash flow and limit billing costs.
We previously tackled radiology claim denials – you can check out a few tips on how to limit these denials by reading our blog post, “Three Tips to Minimizing Radiology Claim Denials.”
Let’s take a look at some of the common issues along with some best practices on minimizing anesthesiology denials for your practice.
1. ‘Not Medically Necessary’ – Not Again!!
One of the most common denials we see in regards to anesthesiology is the ‘not medically necessary’ reason. These denials are fairly consistent between all major healthcare carriers, with the ‘MAC (monitored anesthesia care) denial’ being most commonly linked to these occurrences.
A MAC denial is commonly driven by the assumption that a surgical procedure provided a higher level of anesthesiological care than the required level of care detailed for that service.
Additionally, a claim linked with this denial can be caused by a lack of information or diagnosis; if the diagnosis on the claim does not clearly support the service, the claim will be denied. Also, the frequency of the claim might also cause a denial – for example, two cases in the same day will require an appeal.
Therefore, in order to ensure reimbursement, it’s critical to keep all necessary documentation regarding each service – such as:
These documents will help you prove medical necessity, increasing your chances of claims reprocessing and payment if initially denied.
2. Turning Out-of-network Services into In-network Claims
It’s very common in medical facilities for out-of-network anesthesiologists to perform anesthesia on patients. The issue is that it is normally discovered after the procedure or service that the provider was outside of the patient’s network, leaving that individual with high out-of-pocket expenses they’re responsible for paying. This oftentimes leaves the bill unpaid, or collecting the bare minimum for the service. Costs and payment transparency are now covered for patients in the No Surprises Act, which went into effect January 1, 2022. As a result, regulations will be changing, so we will be monitoring how this impacts billing as events progress.
While not technically a denial since this is more about attempting to collect high out-of-network fees, this is still one of the major issues for anesthesiologists’ RCM efforts. There is a provision that varies from payer to payer – whether it’s RAPS provision, PARE logic, RAPL policy – that enables out-of-network anesthesiologists to have their medical claims processed at a members’ in-network level of benefits.
In many cases, patients with a PPO plan will include out-of-network benefits; be sure to investigate this option for other plans as well. For patients with this provision, their financial responsibilities are lower, greatly improving the chances that they will meet their financial obligation so that the anesthesiologist can be made whole.
3. The Problem with Pre-authorization
A final tip for minimizing anesthesiology denials is realizing that pre-authorization is a common hurdle that you’ll need to deal with. Even though pre-authorization doesn’t really make sense for anesthesia billing, due to the fact that anesthesiologists are blind providers since the patients don’t select them specifically, surgeons will oftentimes require pre-auth. When that happens, commercial payers will deny claims because they don’t have a pre-auth#.
Unfortunately, there isn’t much that can be done to proactively handle these claims before they get denied, so it’s important to have a well-built accounts receivable team in order to deal with these denial trends. Additionally, having a good appeals process is critical for making sure these claims get reprocessed and paid as soon as possible.
Want to learn more about minimizing anesthesiology denials for your practice? Get in touch with an AdvantEdge expert now, or stay up to date on company and industry trends by visiting our LinkedIn page.