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Sickness billing format for Research and Development

so today's learning objectives we're going to describe billable services and providers and we're going to discuss which billable services and providers might be right for your facility we're going to discuss carrier contracting there's various types and there are different regulations for each type we are going to describe provider credentialing ways to maintain it and to keep track of it we're going to explore information technology infrastructure it's very important if you are just starting or building an infrastructure it's important to think through the steps as you are building it and we're going to discuss general billing considerations such as staff the model depending upon your facility size how many employees you might need in other words how many FTEs would make your filling department work so let's start off discussing services and providers so there's different types of services that might fit your facility in your area of expertise medical services such as outpatient which are the general medicine specialties neurology care OBGYN dermatology a lot of attention is currently on mental health services which of course includes behavioral health and of course there's a home and community-based health services physical medicine and rehabilitation we have substance abuse we also have hospice care there's a lot of services out there that you know might fit your type of facility and then you can expand upon those services and then we retain the correct provider for those services so there's also expanded services that would kind of link on to those that main service that you might be thinking about and these services designed to help patients gain access to proper health such as using telehealth home health care medical nutrition therapy is a very popular service now and we also have this diabetic education and vaccine services so you want to select the provider type as I said you want to retain those providers that do understand or are trained for those specific services it ranges from physicians and these indios down to diabetic counselors pas nurse practitioners you know and then of course in the psychology services you can use clinical social workers licensed mental health counselors and substance abuse counselors so it's very important to understand that the licensing and the scope of practice of each provider type can differ state to state so you must be diligent in checking out the license requirements and the scope of practice for the provider type of what service you're looking to provide and of course the scope is limited to which the law allows in your state so let's now talk about carrier contracting so it's very important carrier contracting you know it also is important to understand your your contracts existing if you are just starting out and looking to expand your carriers let's talk about which type of carriers are out there the three basic types of carriers are the HMOs the PPOs and the POS so the HMO is one of the stricter ones it offers comprehensive coverage but typically the HMO patients really have no access to add a network services and they usually require a primary care physician that acts as a gatekeeper as opposed to the PPO which offer patient benefits at a little lower cost the incentives are lower deductibles copays efficient physician reimbursements deepest service you can see physicians usually out-of-network but of course it's at a higher expense the last general carrier contractor is the POS so this point of service plan is a managed care plan it's a hybrid actually of the HMO and the PPO you have to designate an in-network physician that is your primary care provider but you can go to at a network services so of course it's a major federal Medicare Medicaid carriers traditional delivery system they also now have a lot of different managed care models and if those are contracted through various managed care organizations and the MCO which stands for the managed care organization this is the organization that combines the function of the health insurance the delivery of care and the administration these examples would be an IPA which is an independent practice Association third-party administrator M&Ms o which is a management service organization so if you're looking to carry a contract or you already have carrier than just looking to expand first thing to do is make sure your existing contracts are in date and somebody has read them recently to ensure that you are receiving what you should be saving as far as reimbursement then if you want to expand upon your contracting the first thing to do is look at your patient population you want to look at your Medicare and Medicaid local carriers you of course you're going to look at your existing contracted carriers as I said and the reimbursement rates if you're just starting out you might want to just look at reimbursement rates to see if your population fits into any of those carriers that have the high reimbursement rates and start with those so you want to research the carriers in your area also do you have a local perhaps a local union in your area that you get a lot of your patients from of course then you would want to contract with them and then what do you want to do you want to contact that provider relations department ask them any questions that you might have regarding your contracting you know how long it lasts for is it two years is it one year and of course you want to review your local Medicare or your ma C which stands for Medicare administrative contractor covered services all areas of the United States have a different Mac NGS is in New York so that national government services for example so important tips when you are looking at your carrier contracting and these are these are great steps to to take so you want to compile a list of your CPT codes okay so you want to present those CPT codes to the carrier for their fees you want to compare your local max fee schedules to your commercial or your managed care schedules you want to confirm coverage for any highly specialized services performed if your specialty provider sometimes you have a good bargaining chip if you provide high you know specialized high IM c service to your patients your practice a clinic you know it has a specialized service something that is in you know your specialized just in that service and there's not many around that's not a good bargaining tool you want to obtain the data from your billing system you want to look at your carriers that you have your CPT procedure codes lists you know you want to have everything ready when you are speaking with the carrier contact you want to maybe develop a grid of your carriers right now with the CPT codes and the fees that they're giving to produce to present to the carriers that you want to speak to so in your contract is very important that there are certain things in it that are spelled out you want to have all the covered services spelled out in the contract and as I said before in your bargaining tool if you have a specialized service make sure that's clearly written in your contract medically necessary so you want to confirm the list of services and exclusions from coverage you want to make sure those are spilled out spelled out correctly in your contract and easy to understand the reimbursement guidelines you want to know exactly how you're going to be reimbursed and what you must do to be reimbursed the carry a fee schedule that should be noted and you also want to know like I said if it's a year or two year contract termination clauses if the practice o clinic has the right to you know terminate the contract and what is the disband the day span let's speak about an accountable care organizations or an ACL so these a COS were developed by the federal government in an effort to improve outcomes patient outcomes and keep down the cost it all has to do with the value-based payment structure so it's the traditional fee-for-service reimbursement was based upon quantity of service so the ACO or the accountable care organization is based upon quality of service so it's all you know a potential value-based payment model structure so the ACO is a group of health care providers now these providers voluntarily come together to coordinate care it could be different specialties but they all come together to coordinate care and they engage in the value-based payment model of the ACO so CMS designed this program to help you know of course ensure that the patients receive the best care possible but you know the providers are still paid on the fee for service but it creates an incentive for the providers to be more efficient you know by getting that bonus you know but the providers must you know they must do certain certain criteria in documentation and providing different forms of care to the patients and the providers may have to repay Medicare for not providing that that value-based care so it is something you know that needs to be taken seriously and it has to be put into place with structure so the IPA as I had mentioned before which is the independent practice Association is a business entity and it's owned by a network of independent physician practices and what happens with this IPA is that the power in numbers helps negotiate contracts with the managed care organizations so these physician members why's called independent is that these physician members they retained control of their practices ACO not that way so an independent practice Association they do maintain control of the individual business but as I said it's in numbers of the quantity has a good bargaining chip for the carrier contracting so if you want to join an IPA you know they could say what for you know discounts on medical malpractice insurance group purchasing but one of their most notable features is the carrier contracting negotiation so they're all questions that I would ask if I was thinking of joining an IPA or the independent practice associations a lot of physicians do not want to join some of the large health health networks you know Hospital networks that are creating faculty group practices but there are a lot of IPAs out there and there's certain things that I would ask when choosing one how long has it been in existence of course what plans do they contract with rates for plans renewed prior to contracting can we join and only participate in some of the contracts hospital privileges and the course to join some of them don't have a large course some of them have a large course and different regulations can you participate in different IPAs at the same time who manages the IPA and how does this affiliation affect the ACO participation if in fact you are in an ACO at the time you're looking into it hi PA so let's talk a little bit about Medicaid billing so state governments administer of course the Medicaid programs and Medicaid is always the last one to pay for service so when you are billing Medicaid it's very important to understand how to build electronically forms both paper and electronic claim submission might there might be specific regulations covered services thresholds authorization procedures could be different from your commercial carriers fee schedules of course are different and a lot of the reimbursement rules are stricter clearinghouse functions as they relate to processing Medicaid claims very important everything gets set up correctly provide a credentialing so this is very important that goes kind of along with those cons negotiating the contracts provided credentialing if you are thinking of hiring provider and it looks like it goes well on an interview immediately I would start to obtain all the paperwork needed for provider credentialing because sometimes it takes up to 90 days it could take 30 to 45 days for a federal payer but commercial payers could be up to 90 days so let's talk a little bit about provided credentialing what exactly it is and how we can make it effective so of course it's the process whereby the carrier evaluates the qualifications of the provider they ask for all different types of paperwork they review the complete education history the training residency board certification and licenses they asked for driver's license they ask for any malpractice lawsuits anything as such and it's like I said the credentialing process several weeks to months to complete so it is not a good idea for a provider to be seeing patients prior to credentialing so that's why it's important to understand and have a an efficient workflow so insurance carriers will not reimburse any services performed by a non credential provider you know if you may have practices that that think that this could be done but it's strictly stated in the Federal Register that it's considered fraudulent to bill for the services of a provider under another providers name so thinking that this provider can bill under a credential provider is not a good idea some insurance some insurance carriers will back date the contract effective date but that's part of having a good rapport and a good contact with that carrier and make sure that that carrier is cooled and this is you know this information is obtained so see aqh or the council for affordable quality health care is a non-profit lines of health plan the network's nationwide now see aqh is great because it helps streamline the credentialing process and it you know for those plans that are in that database the carrier application process is there is so each carrier can be different online paper form so that's another thing that I would document you know once you get a carrier you know in your system and you credential a few few providers and you know put that method down in writing so it doesn't you know if you don't have to spend time researching how you need to credential again for that carrier if still you have a large practice or clinic more than one staff member you know should be involved in handling this provider credentialing it's very important to keep track a grid of the expire bowls and whatnot which we will go into in detail later some practices elect to outsource credentialing to vendors if they can't handle it but if you have a system and it's set up from the beginning and you're very organized it isn't as complicated as you may think so these are some of the documents that you need for provider credentialing very important to keep spreadsheets and list these on it you have a lot of information here the verification and documentation of course again will vary but you need to have it all up to date and in a folder and ready to provide to a carrier when it's needed so a spreadsheet should be developed to better track your practice or clinic's credentialing efforts as I said a spreadsheet is a great idea in addition to the credential items noted on that previous slide if you put the following fields on it it'll help keep it organized you want the carrier name the application type as I said the workflow was it paper was it by CA qh is it electronic the date you submitted the credentialing application did you verify that they received it and what date was that did they request additional information some carriers won't like something you send them they might have an additional question they will ask for additional information track that down so somebody pulling up that spreadsheet will understand perhaps why there's a delay in this credentialing carrier contact information very important Chev a rapport with one or two people maximum and then of course any notes that you might you know want to put on that spreadsheet for anyone that opens it up so once you B have begun that application process you want to send you know the dates the applications were completed to whoever you know whoever needs to know in billing you want to maintain those records meticulously okay and if you're mailing anything okay always send it via certified mail research return receive requested sometimes the carries will only take paper application so after you submit and you confirm receipt I would follow up again in two weeks I don't you know the only thing is sometimes you know it depends who you are who you are submitting it to and who picks up that credentialing packet you have to keep on that sometimes it takes a little bit longer to get the credentialed and once you begin doing this you will understand the characteristics of each carrier and the neck that you need to credential with that particular carrier so you know it's very important to record everything any conversations you've had so you develop a workflow with each particular carrier so this credentialing grid it should be utilized to assist again with x-pyr Buhl's which is the documents that will expire for the provider credentials the license the DEA and the state license the malpractice so you should always have an expire bolused check it monthly or whoever is doing credentialing so they should check it monthly for any dates that are viable as soon as you see a date that is expiring you reach out to the provider and have them ensure that they they know that they're there Hospital reappointment is expiring or whatever it may be and that - please follow up with the renewal Oh so let's talk about IT infrastructure so now if you are just starting out and developing a billing department or perhaps you're even thinking about practice management system or an EMR you're still using paper charts it's important to learn and think about all the parts of the infrastructure and what you need so of course we have the network the hardware or the software so the network's when you're you're thinking about your network you're thinking about your internet connection the network enablement file and security systems very important to think about your firewall and your security systems because of the HIPAA requirements so one thing that it requires is that you perform a risk assessment an IP risk assessment so you must have these strong strong safeguards in place to protect the patient health information or the pH I so that's something to think about when you're thinking about your network your hardware the course of your servers your computers your switches if you're going to have a server on site if you're going to do cloud-based so hardware is the second important thing so your software so if you don't have any software and you are taking it step by step perhaps you're just thinking about APM or practice management scheduling system then you'll think about getting an EMR or an electronic medical record system and then maybe you're going to attach a billing system it's very important to understand each step if you're buying them separate you want to make sure that these pieces of software are integratable easily so the software your practice management of course would make appointments your EMR would be your charting and your billing would of course be your billing electronic billing sometimes you can you can purchase you know correct certain practice management with billing e/m all with billing but it depends on you know your finances and your strategies for implementation so it's very important to also understand that now we have a lot of cloud-based systems that are you know less expensive something some of the the older hardware I mean software that was offered so what's great about an EMR you know sometimes it's it's hard to change but the good thing is the EMR software provides a lot of key functions in quality care for a patient physician access to the source to the software or the patient information at any time access to the current and previous test results all at once paper doesn't get lost you know papers get lost and if it's in the EMR s and the EMR the doctor will be able to see it computer bought computerized order entry secure electronic communication with other providers patient portals great thing patients can look up their results the patient's access the health records that all part of you know quality of care standards-based electronic data storage reporting for patient safety so it's very it's very important the EMR is a key to quality patient care so the practice management or the PM software that I was speaking about so that maintained your patient demographic information your appointment scheduling your insurance plans and like I said it could also do your billing operations it depends on the software and then your general software that you would want to consider is your email and your office programs security programs in accounting software I can't stress enough that email is very very important a lot of times I'll go into an office and they'll still be using email like Gmail or AOL which doesn't is not secure so you have to be very careful you know if you don't have a 90 on staff get one in as a consultant and just ensure that your email if you you know transferring pH I got to be very careful as that as part of the HIPAA regulations also so when you're selecting your software okay great things to think about when you're considering yourself we had number and types of providers and the clinical support staff some software is based upon your providers and who you know you will pay for that license for each provider clinical support staff you might pay you know somewhere from one to five so it depends on the software that's a great thing to ask about when you're considering the price of the software financial consideration short and long term is it a monthly course or how are they going to be billing you a lot of the cloud-based systems will charge you one flat fee per month you know because you're not buying it so security and confidentiality of the patient medical records it's always good to make sure that that software is secure and HIPAA regulated so you know you're protected so ensure that it's guaranteed to be HIPAA compliant so software selection your EMR software selection is so important we want to make sure that it has templates that fit your facility specialty or if you just internal medicine whatever it may be also ensure that those templates you know have a leeway that they can be adjusted if there's something that you don't like about it ask those questions while you're going through the demonstration you want to make sure that the reporting package of the EMR it reports what you want to see is it macro friendly are you in an ACO and do you need certain reports for the value-based payments patient-centered medical home PCMH very important there's certain reports and certain requirements that PCMH requires so if you are interested in any of these the Mac of the MIPS a CEO or the PCMH always important to ask if the EMI am our software is friendly towards these programs so CMS has certain standards for the EMR software that is certified and that's what I was saying before to make sure that it's HIPAA compliant and if you go on that website listed HTTP backless black actually it's um where the list of the computer programs are that are certified by CMS so now let's speak about billing considerations some general billing considerations on you know basic setting up of your billing department and how to get started selecting a clearinghouse so the clearinghouse is the intermediary between your facility and the carrier so this Clearinghouse it takes your claims okay and then it sends them to the carrier so this Clearinghouse has also a variety of various functions eligibility file status rejection analysis so in other words when you will submit your claims it will if the Clearinghouse sees a claim there's something wrong with it it will reject it and send it back to you so you want to understand you know why your your Clearing House is rejecting that claim to then fix it and then send it off again secondary claims processing secondary carriers Clearinghouse is also good for on ER a the electronic remittance advice which is the payment processing proof of timely filings of you if you have a clearinghouse you're going to you're going to get a report of the date that your claims are filed and that would that's your proof of your timely and paper claim submissions you know your Clearinghouse will help with that paper claim submission so there are various clearing houses out there and the Clearing House what else will it do for you it'll scrub your claims as I said and if it doesn't like something perhaps you know some kind of an edit it'll send it back to you to fix it and then to resend it it'll come it'll make a submission to multiple plans simultaneously claim status from the plan allowing for errors to be corrected prior to submission so insurance eligibility very very important nowadays patients change their insurance so frequently a lot of practices that I service you know we have to get those front desk you know staff members to understand that it's important to collect that insurance card or even just look at it at every visit because patients change their insurance so frequently timely filing of course again it's very important patient statement processing also very important and it's great for reporting tools it'll tell you what was submitted cleanly what was not and it'll tell you final claim submission so the Clearinghouse that you select should be able to tell you a multitude of things of course one of the most important things is the software compatible with your PM system so if you're just starting out and you're looking for a PM system look for a clearinghouse at the same time are the are they contracted with the most common carrier so your clearing has you want it to be very robust you wanted to have you know a good friendship with a lot of carriers or at least the common carriers that your practice builds for what is the clearinghouses proficiency level that's something to ask especially with the government plans because you know Medicare usually turns there out of two weeks so you want to make sure that your clearing has is proficient with the Medicare and the Medicaid claim what is the speed of the scrubbing so in other words once you hit that button for those claims to go how long does it take that Clearinghouse to scrub those claims before they find something wrong with it and send it back is the clearing answer regional or national company you know are there additional costs involved claim submission and eligibility or is everything coming together so there's a lot of questions for you to ask when you're looking for a clearinghouse so another thing very effective for your billing process or your revenue cycle process is electronic funds transfer or EFT so provide the process of the insurance plan to direct deposit payments okay no checks I'll go into the bank it's it's safe convenient timely standards for the electronic payment and remittance you know it's great because it's under the HIPAA regulations so it's you know it's suggested to do this instead of having things come through the mail payment is process and deposit into your bank so the EFT function really allows for time it's time it frees up time and also it's faster access to to the funds you don't have staff we're having to work and on you know the checks going to the bank record-keeping so and like I said it's a faster access to the funds of the organization so another another term is the lock box and this is also something that is effective in your revenue cycle process so the lock box is it's a system whereby paper insure correspondence and payments patient correspondence and payments and all of the correspondents are issued directly to the practices financial institution okay instead of going to the practice itself or you know the location so it requires the practice utilize a designated post office box okay checks is deposited into that designated account and all other related documentation is scanned and then put into that lockbox you know the EO B's or whatever it may be and these documents then are accessible of course it can either a burdens for office staff because yo B's you know when you receive them by mail you have to open up the envelope you have to you know look at them you might want to file them you scan them whatever you do the lock box is a great alternative because it prize it's like processing your mail that you don't have to process so considerations just as we have considerations in picking a clearinghouse there's things to think about if you're deciding to use a lock box and what what are these things are the checks or the EOB is returned to the practice view paper or online electronic archiving system so that would be something that you want to know how often does the financial institution download the claim correspondence and pay payments the denial files are they processed separately from the payment files options available for denials management's very important financial institution will it provide the facility with electronic access HIPAA compliant of course you want to make sure that a typical client because it's containing EOB and patient information is the solution cloud a lot of them are now lockbox speech is a standard and which represent additional costs same thing as the Clearinghouse you want to ensure what you're getting and what you're paying for so the advantages and disadvantages of the lockbox so this very the disadvantages really are not not as great as the advantages so the disadvantages could be that the funds would go to the wrong account you would be missing an EOB received incorrect do fees or potential delays and obtaining copies of EOP I have seen it very rarely happened that any of these four items have happened the advantages do outweigh the disadvantages as I said the financial institution sometimes offsets the cost involved in that Lockbox if this certain balance kept in the account the employee time spent on all the related tasks that these black boxes perform is great and it reduces potential fraud and embezzlement activities I have seen you know missing checks and some practices so you have to be very careful the lockbox really does does have a lot of advantages so I'd like to present the case study ah has to do with credentialing and it it will show you at the end of why credentialing is so very important so let's read this challenge it's from John Hopkins old Children's Hospital so the challenge was that John Hopkins old Children's Hospital the enrollment process was slow and inefficient and as I said some carriers take up to 90 days is so many documents you need sometimes it's hard to get them from the why it is because it provided don't understand how important it is for them to be credentialed so we slowed inefficient with an average enrollment time of six months now I was speaking 90 days they were having six months new physicians were frustrated as its delayed when they could start seeing patients right away so what was going on here was that you know it was realized that there was duplicate components of provider enrollment and medical staff credentialing so in a hospital you'll have medical staff credentialing and then you'll have maybe a probe provider enrollment department it was decided to combine these two departments because a lot of time medical staffing collects documents and then you know the provider enrollment correct collects documents so they decided to combine these two departments together and then the information the medical staff office gathers impacts of course the enrollment team so instead of working in silos the core server information was not accessible both teams had access to the same information everybody needed the same information so that's why I things got a little bit better I have to say that a lot of time obtaining those documents is the problem it's very hard to chase down some providers so as I said if you're your facility thinking of bringing on providers you like that provider you're going to hire them you must get those documents I would start getting these Doc's those documents ASAP so what was the result the statistical results were pretty surprising for the hospital successfully cut enrollment days in half for eight of the top twelve pairs which is amazing in February 2015 less than 50% of all employee providers were active with payers by February 2016 and increased by twenty percentage points by the end of 2016 over 77% of employee providers were active with payers while the volume of providers continuously increased so obviously they got a system going they probably had a good tracking system I mean if you usually if you outsource credentialing there are some credentialing large credentialing vendors that have software there are even credentialing vendors that have their own software that will sell you or rent it to you for a fee to have their software like a tracking tool you just use their software map their services or you know vice versa in February 2015 over half the provider applications were in the queue non-participating provided status by the end of 2016 13 percent remained decrease of thirty eight percentage points so a lot of times you know they'll be in the queue you'll be missing documents that that is one of the most common problems you can't get the the document and then when it comes time for recrudescence keep those expire wills up to date because once you have have you know a date to re credential a provider you want to make sure you have all those documents in their file that occurrence and then you can just send them in you know keep the process flowing a monthly check of your credentialing records is the best bet so today's module one highlights we talked about selection of medical services and provided types to best suit your practices missions and goals then we also talked about once we select those services there are other services that can enhance those services such as medical nutrition therapy you know other other behavioral health services perhaps we talked about strategies for optimal contract negotiations with carriers we you know you perform your service but you want to get optimal you want to get optimal reimbursement so you should be contracting you know negotiations you know streamlining them understanding the contracts you have making sure that the expiration dates are either you know kept on a grid or somebody's reviewing those contracts yearly provide a credentialing techniques another very important part of your revenue cycle you know provider credentialing if you do not keep up with it will keep track of it you know your denials you might be getting denial saying provider is not in plan you know and why maybe you lapse in your credentialing you know and that could be detrimental you know if that carry is going to take another 30 days to get your provider re credentials again so it's very important to look at those dates and those expire ball the IT infrastructure development we talked about a few things to think about if you're just beginning on your way to electronic medical records or perhaps electronic billing we talked about different parts of the billing the billing structure such as the Clearinghouse the EFT the benefits of the cash you know cash flow utilization of a lockbox the streamlining the collection in the payment processes and how these different parts may free up staff time and benefit your practice so I'd like to share this slide with you module one a little mini assignments or actually just things for you to think about you know on your way to billing to to building a better billing department or building up your services so prepare a list of any proposed services or provide types that you think you could consider for your practice create a spreadsheet of your existing carriers and initial contract days expiration dates any known CPT codes and their associated fees or provide your current carrier contract spreadsheet in other words review that current spreadsheet if you have one is anybody reviewing it you might be keeping one but is anybody really looking at it prepare a credentialing grid as we described in the slides with the particular you know headlines and sections list all current software what are the challenges that you might be having with that software has anybody actually sat down with the software the software vendor and address these problems you know sometimes we get so caught up in our daily activities that things that are slowing us down we don't take the time to try to fix them do you have a clearinghouse do you like your Clearinghouse advantages and disadvantages of it you know you can outweigh the benefits maybe you can change to a clearinghouse like I said also look into what you're paying for are you paying for separate eligibility you know separate you know that everything you ask them to do this in your contract are you paying separately review your contracts draft a list of questions regarding utilization of the EFT after we just discussed it today maybe those questions would help you think about that it can help a u.s. facility the same thing with the lab box make some questions if you have any you know more questions about the lock box look into it there's a lot of information online about the advantages and disadvantages of that lock box so I hope you have had a very enjoyable experience today we have come to the end of module 1 of the in Hanceville hansung billable services online learning module series thank you for trusting your training and technical assistance needs with the sustainable strategies for Ryan White hiv/aids program community organizations program for questions regarding today's module please contact us at HRSA at P CDC org for more information about our program products and services please visit our webpage on the target HIV website thank you and have a great day