revenue cycle Archives

Billing/RCM

Root Cause of Medicare Claim Denials

Written By Teresa Bolden, CPC, CPMA, CEMC, CHBS, Medicare Compliance Consultant

Root Cause Analysis (RCA) is an important claims management tool to improve billing compliance. It is a systematic problem-solving technique used to identify the underlying causes of a particular issue or problem, rather than addressing only its symptoms. It involves a structured approach to investigating and understanding why something happened, with the goal of preventing its recurrence. Applying RCA to analyze how and why claims are denied not only improves your bottom line, but reduces future denials, improves the organization’s ability to push-back on inappropriate denials and increases billing compliance through a documented process.

Introduction

Accuracy must be the focus of documentation, coding and billing compliance efforts. Analyzing denial trends which may exist in your Accounts Receivable (A/R) is the place to start. But understanding how Centers for Medicare & Medicaid (CMS) views fraud versus abuse is equally important. Download the CMS Medicare Fraud & Abuse: Prevent, Detect, Report Booklet for more information, but in short note the following:

When you submit a claim for services provided to a Medicare beneficiary, you are filing a bill with the Federal government and certifying you earned the payment requested and complied with the billing requirements. If you knew or should have known the submitted claim was false, then the attempt to collect payment is illegal. When Medicare denies a claim, review documentation and billing to evaluate whether it can be appealed. Examples of improper claims which should not be appealed, but written off and are subject to further investigation by CMS often include:

Billing codes that reﬂect a more severe illness than actually existed or a more expensive treatment than was provided
Billing medically unnecessary services
Billing services not provided
Billing services performed by an improperly supervised or unqualified employee
Billing services performed by an employee excluded from participation in the Federal health care programs
Billing services of such low quality they are virtually worthless
Billing separately for services already included in a global fee, like billing an evaluation and management service the day after surgery

CMS and the Office of Inspector General (OIG) expect providers and physicians treating Medicare beneficiaries to establish an effective compliance program. Establishing and following a compliance program helps physicians avoid fraudulent activities and submit accurate claims. The following seven components provide a solid basis for a physician practice compliance program:

Conduct internal monitoring and auditing
Implement compliance and practice standards
Designate a compliance officer or contact
Conduct appropriate training and education
Respond appropriately to detected oﬀenses and develop corrective action
Develop open lines of communication with employees
Enforce disciplinary standards through well-publicized guidelines

Understanding Medicare Claim Denials

Medicare claim denials can be a significant source of frustration and financial strain for the healthcare community. While seasoned coding and billing specialists are knowledgeable about root causes for common denials, they too find it challenging at times to dodge the obstacles that result in claim denial. To begin the RCA process, it is vital to gain an understanding of how the payer determines a denial. CMS publishes the most common reasons for Medicare denials by category as follows:

Duplicate claim/service
Bundled service/procedure
Care covered by another payer
Medical necessity
Non-covered service/item

Understanding root causes for claim denials is crucial for improving claim acceptance rates and ensuring timely reimbursement. Below we explore the most common reasons for Medicare claim denials and insights into how to avoid unnecessary denials

1. Duplicate claim/service.

Duplicate claim denials continue to be one of the top billing errors among all Medicare Administrative Contractors (MACs). A duplicate denial indicates that more than one claim was submitted for the same service, for the same patient, for the same date of service. In most instances, the claim was already processed and paid. While some claims are exact duplicates of previously submitted claims, some services are denied as duplicates for other reasons. The following reason and remark codes are examples of common duplicate claim/service denial messages:

Reason CODE	Remark Code	Definition
18		Duplicate claim/service.
	M86	Service denied because payment already made for same/similar procedure within set time frame.
	N20	Service not payable with other service rendered on the same date.
	N327	Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer.
	N522	Duplicate of a claim processed, or to be processed, as a crossover claim.

AVOID DENIALS FOR EXACT DUPLICATES

Allow 30 days from the claim receipt date before submitting a subsequent claim for the same service(s).
Use the MACs free online portal or Interactive Voice Response (IVR) to check the status of the initial claim before submitting a subsequent claim.
Investigate the reason for denial, rather than simply resubmitting the claim. Some physicians/QHPs will refile a claim to correct a previously denied claim. This resubmission can cause an unnecessary duplicate denial when the initial claim processed correctly.
Correct the following clerical errors through your MAC’s IVR or online portal:
- Change the referring provider name and National Provider Identifier (NPI).
  - The rendering provider’s NPI may not be changed.
- Change the number of services or units.
- Add or change claim diagnosis codes.
- Add, change or delete eligible modifiers.
  - Excluded modifiers are: 22, 24, 52, 53, 55, 62, 66, 80, 81, EA, GA, GX, GY
- Change the procedure code.
- Change the date of service.
- Change the place of service.
- Change the billed amount.

A physician or other QHP may perform multiple procedures or “repeat procedures,” to the same patient on a single day. All services provided to the same patient, by the same physician/QHP, on the same date of service should be billed on the same claim.

AVOID DENIALS FOR REPEATED PROCEDURES

When appropriate, use a unit of service multiplier rather than billing the same CPT/HCPCS code on multiple lines.
Drug codes - bill the HCPCS code for drugs according to the dosage in the code’ description and add a multiplier on the claim to show the appropriate dosage. For example, the HCPCS descriptor states 1 mg and 4 mg are administered, the drug should be billed with 4 units of service (UOS).
Drug administration fee – bill one UOS for each intramuscular administration of therapeutic drugs on one line (i.e., 96372). The UOS billed should equal the number of separate injections.
Use one of the following modifiers to report services or procedures repeated on the same day:
- 76 – Procedure or service was repeated subsequent to the original procedure.
- 77 – Repeat procedure or service by another physician or other QHP subsequent to the original procedure.
- 91 – Repeat clinical diagnostic laboratory test.

NOTE: Include a narrative description indicating the reason for the repeated procedure in item 19 of the 1500 claim form or the electronic equivalent.

2. Bundled service/procedure.

There are several scenarios in which a service or procedure does not receive separate reimbursement because payment for it is included in Medicare’s payment for another service or procedure. The most common form errors falling under the category of bundling denials identified by CMS:

Items are always bundled;
Lack of accurately applying the National Correct Coding Initiative (NCCI) edits; and
Errors made related to global surgery claims;

Always bundled. Some services/procedures are “always bundled” for Medicare purposes and never receive separate reimbursement, even from the patient. Those services/procedures have a status indicator of “B” or “P” in the Medicare Physician Fee Schedule (MPFS) Relative Value File (Addendum B of the MPFS Final Rule). The common reason and remark codes used for always bundled services/procedures are:

Reason CODE	Remark Code	Definition
125		Submission/billing error(s)
	N19	Procedure code incidental to primary procedure.
	M15	Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.
	M80	Not covered when performed during the same session/date as a previously processed service for the patient.

AVOID ALWAYS BUNDLED DENIALS

Identify the status indicator for all services provided by reviewing the MPFS Relative Value File annually. Flag services/procedures that have a status indicator of “B” or “P” as non-billable charges.

National Correct Coding Initiative (NCCI) Edits. The Centers for Medicare & Medicaid Services (CMS) developed the NCCI program to promote national correct coding of Medicare Part B claims. The purpose of the NCCI Procedure to Procedure (PTP) edits is to prevent improper payment when incorrect code combinations are billed. The NCCI contains one table of edits for physicians and other qualified healthcare professionals (QHPs) and one table of edits for outpatient hospital services. The NCCI PTP edits are available free of charge from the CMS website.

The CMS also developed the NCCI Medically Unlikely Edits (MUE) program to prevent improper payments when services are reported with incorrect units of service. The NCCI MUEs assigned to each CPT/HCPCS code are in the NCCI PTP edit table.

The common reason and remark codes for NCCI bundled services/procedures are:

Reason CODE	Remark Code	Definition
97		The benefit for this service is included in the payment/allowance for another procedure or service that has already been paid.
4		Procedure code is inconsistent with the modifier, or a required modifier is missing.
	M80	Not covered when performed during the same session/date as a previously processed service for the patient.
	M362	The number of days or units of service exceed our acceptable maximum.

AVOID NCCI BUNDLED DENIALS

Download the most recent PTP edits.
- Locate the code pair in the Column1/Column 2 List. The Column 2 code is considered a component of the Column 1 code.
- Review Column F to determine if a modifier may be appropriate for the situation.
Review the NCCI Policy Manual that is available in the NCCI section of the CMS website. The policy manual provides additional details regarding PTP edits along with exceptions and instructions for using modifiers.
Use encoder software to identify bundled services and modifier opportunities.

Global Surgery Edits. The global surgical package, also called global surgery, includes all necessary services normally provided by a physician (or members of the same group with the same specialty) before, during, and after a procedure. Medicare physicians in the same group practice, with the same specialty, must bill and accept payment as though they are a single physician. Global surgery applies in any setting, including an inpatient hospital, outpatient hospital, ambulatory surgical center (ASC), and physician’s office.

The Medicare physician fee schedule (MPFS) includes all procedure codes and global surgery indicators. The global surgery payment rules apply to procedure codes with global surgery indicators 000, 010, 090 and sometimes, YYY. Definitions for the most common global surgery indicators are as follows:

000 codes identify endoscopies and some minor surgical procedures. The Medicare allowable includes the cost of the related E/M service provided on the same day.
010 codes identify other minor procedures. The Medicare allowable includes the cost of the related E/M service on the same day, plus 10 days following the procedure.
090 codes identify major surgeries. The Medicare allowable includes the cost of the related E/M service provided the day before the surgery, day of the surgery, plus 90 day following surgery.

NOTE: Refer to the CMS publication of Global Surgery (MLN907166 December 2023) for complete guidelines and exceptions to global surgery rules.

The common reason and remark codes for bundled services due to global surgery are:

Reason CODE	Remark Code	Definition
97		The benefit for this service is included in the payment/allowance for another procedure or service that has already been paid.
	M80	Not covered when performed during the same session/date as a previously processed service for the patient.
	M144	The cost of care before and after the surgery or procedure is included in the approved amount for that service.
	N20	Service not payable with other service rendered on the same date.

AVOID GLOBAL SURGERY BUNDLED DENIALS

Bill E/M service(s) provided during the postoperative period for a reason(s) unrelated to the original procedure, with modifier 24.
A significant, separately identifiable E/M service provided on the same day as a minor procedure, may be billed with modifier 25.
- NOTE: This one of the most commonly misused modifiers. Refer to your local MACs instructions for using modifier 25. According to Medicare, the decision for surgery is always included in the allowance for a minor surgical procedure. (Reference: IOM Publication 100-04 Chapter 12.40.1.B)
Critical care provided on the same day or during the postoperative period that is unrelated to the surgical procedure should be billed with modifier FT.
When the need to perform major surgery within 24 hours is decided during an E/M service, bill the E/M with modifier 57 (decision for surgery).
It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure. When the patient returns to the operative suite to address postoperative complications, bill the unplanned surgical procedure with modifier 78.
An unrelated surgical procedure(s) performed during the postoperative period of another procedure should be billed with modifier 79.
It may be necessary to indicate that the performance of a procedure or service during the postoperative period was (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. When one of these circumstances apply, bill the procedure with modifier 58.

3. Claims sent to the wrong payer/contractor.

Medicare law and regulations require all entities that bill Medicare for services or items given to Medicare beneficiaries to decide whether Medicare is the primary payer for those services or items before submitting a claim to Medicare (Reference: Section 1862(b)(2) of the Social Security Act and regulations at 42 CF 489.20g).

Medicare Secondary payer (MSP) provisions protect Medicare from paying when another entity should pay first. Medicare may be secondary if the patient falls under any of the following reasons:

MSP Type	Secondary Coverage Reason
Type 12	The patient is an aged worker or spouse with an employer group health plan of more than 20 employees.
Type 13	Is covered under an End Stage Renal Disease (ESRD) coordination period, which is typically the first 30 months.
Type 14 or 47	Is covered under a no-fault plan, which usually includes any liability or auto claims.
Type 15	Is covered under a workers’ compensation claim.
Type 42	Is covered under a Veterans Administration plan and is not being attended within a VA facility or a VA physician.
Type 43	Is disabled and the employer’s group plan has 100 or more employees.

NOTE: Medicare’s publication of Medicare Secondary Payer MLN006903 dated October 2023 includes common MSP Coverage Situations

There are several situations in which a local Medicare Administrative Contractor (MAC) is not the appropriate payer/contractor to process a claim for a Medicare patient. Besides traditional Medicare, Congress created a Medicare Advantage option that allows private insurance companies offer coverage to people with Medicare, giving them more choices. These Medicare Advantage options (sometimes called Part C) include:

Medicare Health Maintenance Organizations
Preferred Provider Organizations
Private Fee-for-Service Plans
Medicare Medical Savings Account Plans
Medicare Special Needs Plans

The common reason and remark codes for claims sent to the wrong payer/contractor are:

Reason CODE	Remark Code	Definition
22		This care may be covered by another payer per coordination of benefits.
24		Charges are covered under a capitation agreement/managed care plan.
109		Claim/service not covered by this payer contractor. You must send the claim/service to the correct payer/contractor.
	MA92	Missing plan information for other insurance
	N193	Alert specific federal/state/local program may cover this service.

AVOID INCORRECT PAYER DENIALS

Collect full patient health information upon each office visit, outpatient visit, and hospital admission.
Patients that elect coverage through a Medicare Advantage (MA) plan still keep their original red, white and blue Medicare cards. Be sure to ask to see all of their insurance cards.
- Patients may elect new plans each year. In some situations, coverage may change in the middle of a calendar year.
Find the primary payer before submission of a claim, and bill the proper responsible payer(s) for related services.
Use the MAC’s IVR to verify whether Medicare is primary or secondary for specific patients prior to submitting claims.
For multiple services, bill each responsible payer(s) separately.
Do not bill for treatment provided for accident-related services and non-accident-related services on the same claim. Send separate claims to Medicare: one claim for services related to the accident and another claim for services not related to the accident.
Always use specific diagnosis codes related to an accident or injury. Doing so will promote correct and prompt payment. Do not forget to report ICD-10-CM external cause codes.
Download and review the quick reference table for common MSP coverage situations in MLN006903 dated October 2023.

4. Not Covered Due to Medical Necessity

Section 1862(a)(1) of the Social Security Act (the Act) states no Medicare payment shall be made for expenses incurred for items or services that “are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” To that end, CMS developed National Coverage Determinations (NCDs) to determine if a specific item or service is covered by Medicare nationally. Each NCD is based on evidence, limiting coverage to items and services that are considered “reasonable and necessary” for treating or diagnosing an illness or injury. NCDs can be found online in Internet Only Manual (IOM) Publication 100-03.

Some services are processed according to a Local Coverage Determination (LCD) and its accompanying Billing/Coding Article. These resources identify coverage criteria, frequency limitations, documentation requirements, coding guidelines and medical necessity. LCDs are decisions made by MACs that apply to services provided to Medicare patients within the specific jurisdiction that the MAC oversees. The common reason and remark codes for medical necessity denials are:

Reason CODE	Remark Code	Definition
50		These are non-covered services because this is not deemed a “medical necessity: by the payer.
	N115	This decision was based on a Local Coverage Determination (LCD).

AVOID MEDICAL NECESSITY DENIALS

Stay up-to-date with Medicare’s coverage policies and guidelines.
Ensure that medical records comprehensively document the patient’s condition and the necessity of the services provided.
Use encoder software to identify medical necessity concerns.
If a patient decides to receive the item/service that Medicare considers not medically necessary, be sure to obtain an Advance Beneficiary Notice (ABN) before providing the item or service.
- NOTE: The CMS developed an Advance Beneficiary Notice of Non-coverage Tutorial (MLN909183 May 2023).

5. Non-Covered Service/Item

Some services are statutorily excluded from Medicare coverage. Examples include custodial care, cosmetic surgery, personal comfort items and services, items and services required because of war, routine or annual physical checkups (with certain exceptions). In general, healthcare providers are not required to submit claims to Medicare for statutorily excluded services. There are times, however, when the patient requests the service(s) to be submitted in order to obtain a denial for secondary insurance purposes. In this case, submit statutorily excluded services with modifier –GY (item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit). The common reason and remark codes for non-covered items/services are:

Reason CODE	Remark Code	Definition
96		Non-covered charges.
	N425	Statutorily excluded service(s).
Cell	N431	Not covered with this procedure.

AVOID UNNECESSARY NON-COVERED SERVICE/ITEM DENIALS

Download and review CMS publication of Items & Services Not Covered under Medicare (MLN906765 June 2022).
Notify the patient that the item/service is statutorily excluded from coverage.
- NOTE: The ABN may be provided to Medicare beneficiaries as a courtesy, to inform them of their financial responsibility for services that are statutorily excluded from Medicare coverage. Healthcare providers are not required to use an ABN to notify patients about statutorily excluded items/services.
Do not bill statutorily excluded services to Medicare unless the patient requests it.
Append modifier –GY to statutorily excluded services that are billed to Medicare.

Conclusion

Maintain accurate and complete medical records and documentation of the services you provide. This ensures improved coordination of care, quality and improves your ability to appeal and have denied claims overturned. Conduct pre-billing audits periodically to verify that documentation supports the claims you submit for payment.

When your analysis identifies a trend in the type of denials, implement the RCA approach. Learn more about Root Cause Analysis by enrolling in the Auditing for Compliance, online course offered by AIHC.

About the Author

Teresa Bolden,CPC, CPMA, CEMC, CHBS, is a Medicare Compliance Consultant and serves on the AIHC Volunteer Education Committee. Article edited by Joanne Byron, LPN, CCA, CHA, CHCO, CHBS, CHCM, CIFHA, CMDP, OHCC, ICDCT-CM/PCS of the American Institute of Healthcare Compliance (AIHC), a non-profit healthcare education organization.

Share 0

Post 0

Share 0

Billing/RCM

How to Achieve an Efficient Cardiology Medical Billing Process

Written by: Eve Liam

The evolving healthcare industry makes the revenue cycle management complex and billing teams need to stay aligned with the latest updates. Likewise, changes in the billing guidelines and technology integration in healthcare makes cardiology medical billing challenging. In addition, billers and coders who handle cardiology RCM processes should be qualified enough to ensure quality reimbursements. Further, cardiologists need to keep the cash flow consistent and drive better patient health outcomes. An efficient billing process leads to greater productivity, improved profitability, and reduced denial rates. Let’s see how cardiology practices can achieve an efficient billing process.

Improve Clinical Documentation

Accurate clinical documentation is the most important aspect of an efficient revenue cycle management. In addition, documentation is used to maintain healthcare information of the patients which is used to submit claims. Similarly, it improves the quality of the health records and acts as a foundation of the revenue cycle. As a result, cardiology practices can achieve full and on-time reimbursements from payers. Hiring cardiology billing services can help improve clinical documentation and guarantee complete payments. Appropriate documentation makes it easier for all the stakeholders to understand the services offered to the patients.

Verifying Insurance Eligibility

Checking the insurance details help cardiology practices to get details of patient’s insurance coverage, copayments, and deductibles. In addition, this process gives a complete idea about the patient’s insurance and helps providers save their time and money. Offering services which are not covered by the insurance company leads to claim denials and revenue losses. So, billing services for cardiology practices streamline cash flow and prevent claim denials. Knowing the patient’s eligibility before the appointment scheduling saves time and helps practices to find out which services to offer.

Perform Medical Billing Audits

To make sure that the billing process is running efficiently, cardiology practices need to find problematic areas in the RCM cycle. The best way to find errors in the billing process is to perform a medical billing audit. In addition, cardiology medical billing audits help you identify key areas that need immediate attention. As a result, practices are able to check the effectiveness of the clinical documentation and the billing process. Third-party RCM vendors offer billing audit services for specialty practices. If it is not easier for cardiology practices to perform an in-house billing audit, they can outsource it. Moreover, going for an external audit helps to scrutinize the overall revenue cycle management process.

Keep Aligned with the Billing and Coding Changes

Healthcare industry rules are constantly changing and billing staff should stay updated with the latest rules. Additionally, medical practices can reduce revenue leakages and optimize the revenue cycle process by staying updated with the latest rules. CMS keeps on updating the guidelines on how to bill and code for services cardiologists render. Thus, it is essential to stay updated with the latest guidelines and submit clean claims for optimal payments. Getting billing services for cardiology practices reduce the chances of errors because third-party billers are updated with the latest changes. Further, it increases the efficiency of the overall revenue cycle management process and allows practices to improve workflow efficiency.

Outsource Cardiology Billing to Experts

There is always an option to hire industry experts who are well-versed with the ins and outs of the billing process. Also, the staff of medical billing companies is certified and highly professional. In this way, outsourcing billing helps cardiology practices to streamline revenue cycle and achieve an efficient billing process. In addition, RCM companies are updated with the latest developments in the healthcare industry with respect to billing guidelines. So, hiring third-party billing services can help optimize profitability and increase workflow efficiency. Further, cardiologists can improve the health conditions of patients by focusing on providing quality care. Consequently, it can significantly improve the health conditions of the patients.

Prevent Medical Billing and Coding Errors

Accuracy is the most important thing when it comes to the claim submission process. In addition, clinical documentation should be accurate to ensure error-free claim submission. Also, an efficient claim scrubbing process improves the chances of claim acceptance. Likewise, cardiologists can reduce payment delays and claim denials with billing and coding accuracy. The billing staff should know the correct and the latest CPT codes required to submit claims. Moreover, lesser chances of claim denials mean greater chances of greater reimbursements. So, cardiology practices should focus on submitting accurate claims to the payers and make the billing process efficient. Lesser errors lead to an effective medical billing process and streamline payments from payers.

Final Thoughts

Not having an efficient cardiology medical billing process makes it difficult to manage the revenue cycle efficiently. In addition, an effective claim submission process should be properly implemented to ensure seamless reimbursements and avoid potential revenue losses. Similarly, eligibility verification and prior authorization help save time and effort for providers. To keep medical billing efficient, it is essential to perform regular audits and stay updated with the billing guidelines. Lastly, outsourcing helps to work with industry experts who can help reduce billing errors, mitigate compliance risks, and help achieve timely reimbursements.

Author Biography:

Eve Liam has been working as a Medical Billing and Coding expert for the last eight years with a widely known and reputed medical billing services provider Physician Billing Company. Eve is known for her expertise in Healthcare Information Technology, Revenue Cycle Management Training, and Healthcare Management, and her unique tactics to deal with medical billing claims bring drastic changes in annual revenue.

Share 0

Post 0

Share 0

Billing/RCM

Collection Strategies for Aged Accounts Receivable in the Revenue Cycle Management Process

Written by: Awais Ghaffar

If you’re like most businesses, you’re relying on accounts receivable (AR) to keep your business afloat. But what happens when those payments start to lag? You might have a process in place for collecting aged accounts receivable, but it might not be as effective as it could be. In this blog post, we’ll explore some strategies for collecting aged accounts receivable in your revenue cycle management process. From outsourcing to collection agencies and more, we’ll help you get a handle on those delinquent payments and keep your business running smoothly.

The problem with aged accounts receivable recovery

The problem with aged accounts receivable is that they can be a drag on your business's cash flow. When customers don't pay their invoices on time, it can put a strain on your working capital and make it difficult to meet your own financial obligations.

There are a few strategies you can use to collect aged accounts receivable and improve your cash flow situation:

Send out reminders: Send polite reminders to customers who have outstanding invoices. This may prompt them to take action and pay their bill.
Offer discounts: You may be able to entice customers to pay their bills by offering a discount for early payment.
Use collection agencies: If all else fails, you can turn the account over to a collection agency that will use more forceful tactics to get the money owed to you.

While these strategies may help you collect some of the money owed to you, they won't solve the underlying problem of why customers aren't paying their bills on time. To truly fix the issue, you need to get to the root of the problem and figure out why your customers are falling behind on their payments. Once you know what's causing the issue, you can put processes in place to prevent late payments in the future.

The revenue cycle management process

The revenue cycle management process is a critical part of ensuring that your business is able to collect on its aged accounts receivable. There are a number of different strategies that you can use in order to increase your chances of collecting these outstanding amounts, and it is important to consider all of your options in order to find the best solution for your business.

One common strategy for collecting aged accounts receivable is to offer a discount for prompt payment. This can be an effective way to incentivize customers to pay their outstanding balance, and it can also help to improve your cash flow. Another option is to set up a payment plan with the customer, which can help them budget for the repayment of their debt.

If you are having difficulty collecting on an aged account, you may also want to consider using a collection agency. Collection agencies specialize in pursuing outstanding debts, and they may be able to help you recover the money that you are owed. However, it is important to remember that using a collection agency will likely result in additional fees being added to the outstanding balance.

The revenue cycle management process is critical for businesses of all sizes, and there are a number of different strategies that you can use in order to collect on outstanding debts. It is important to consider all of your options and find the solution that works best for your business.

Tips for collecting aged accounts receivable

If you're like most businesses, a large portion of your revenue comes from accounts receivable (A/R). And if you're like most businesses, a significant portion of your A/R is aged, meaning it's been outstanding for more than 30 days. Collecting on aged A/R can be challenging, but it's essential to maintaining a healthy cash flow. Here are some tips to help you collect on aged accounts receivable:

1. Understand why the invoice is aged
Before you can take steps to collect an aged invoice, it's important to understand why it's aged in the first place. There could be a number of reasons, such as:

The customer is disputing the charges
The customer has financial difficulties and is unable to pay
The customer never received the invoice
There was an error on the invoice

Understanding the reason for nonpayment will help you determine the best course of action for collecting the debt.

2. Communicate early and often with your customers
Proactive communication with your customers is key to preventing invoices from becoming aged in the first place. When an invoice is generated, make sure to follow up with the customer right away to ensure they received it and that there are no questions or concerns about the charges. If payment isn't received within a reasonable timeframe, reach out again to inquire about when payment can be expected.

The benefits of collecting aged accounts receivables

There are many benefits to collecting aged accounts receivable. Perhaps the most obvious benefit is that it allows you to keep your business running smoothly by ensuring that you have the cash flow you need to cover your expenses.

In addition, collecting aged accounts receivable can help you improve your relationships with your customers. When customers know that you are actively working to collect payments, they are more likely to respect and appreciate your efforts, which can lead to improved communication and collaboration down the line.

Finally, collecting aged accounts receivable can also boost your bottom line. The sooner you collect on past-due invoices, the less interest you will accrue on those balances. In addition, if you offer early payment discounts, you may be able to save money on future purchases made by customers who take advantage of those offers.

Conclusion

There are a number of strategies you can use to collect aged accounts receivable in your revenue cycle management process. The most important thing is to be proactive and take action as soon as an invoice becomes overdue. Use a mix of methods to reach out to customers, including phone calls, emails, and even snail mail. And consider using a collection agency if you're having trouble getting paid. By following these tips, you should be able to collect the money that's owed to you without too much hassle.

About the Author

Awais Ghaffar has been working as a medical billing expert for the past five years with a well-known and reputed medical billing services provider Medcare MSO. Awais is known for her expertise in Healthcare Information Technology, Revenue Cycle Management Training, Healthcare Management and her unique tactics to deal with medical billing claims.

Billing/RCM

Best Practices in Patient Eligibility and Benefits Verification

Written by: Melvin Miller, Chief Operating Officer

With rising consumerism, patients have increasing responsibility for payments. The growth of high deductible health plans (HDHPs) is a clear indicator of this trend. It is, therefore, important to clearly understand the patient's responsibility for payments upfront and determine coverage.

This article highlights the importance of patient eligibility and benefits verification.

What is patient eligibility and benefits verification?

A healthcare practice must verify a patient's coverage for medical services and determine their responsibility for payments. Through the patient eligibility and benefits verification process, physician practices can confirm the coverage offered by the health plan and copayments, deductibles, and co-insurance with the health plan.

Verification of eligibility promotes the collection of the coverage status and reduces the likelihood of claims getting denied. It enables healthcare providers to collect payments from patients proactively and prevents delays in cash realization.

Information to be provided for patient eligibility and benefits verification

One of the fundamental components of the front-office tasks is to collect the patient details upfront and enable the verification of benefits by insurance verifiers.

Healthcare providers must train staff members on the insurance verification processes. Efficient processing reduces the likelihood of denials and accelerates the cash flow cycle.

Electronic and manual eligibility verification processes

Most payers have made available interfaces to check eligibility online. By verifying eligibility electronically before the scheduled patient appointment, you will be able to:

Get accurate information about the patient's insurance status and understand the benefits of the health plan.
Determine if you must collect a co-pay at the time of service.
Update insurance details.
Get patients to update primary care physician details.

Sometimes, it may be necessary to call the payer with questions related to prior authorization requirements or clarify some eligibility and benefits elements.

Timeliness of eligibility checks

Healthcare providers must check eligibility at least 48 hours before the visit. Should this not be possible, it can be done in real-time during check-in before the treatment. Timely eligibility checks help you reduce claim rejections and denials. Most electronic health records and revenue cycle management systems have electronic eligibility checking functionality. By verifying the patient's coverage before care delivery, your practice will be able to reduce denials and improve revenue realization.

Importance of process documentation

The needs of your practice are unique. A substance use support clinic has very different eligibility verification requirements from a hospital or radiology clinic. Hence, each institution must create specific eligibility and benefits verification workflows. All your team members need to collaborate effectively and ensure efficient completion of all steps.

Checklist for eligibility verification

The following are some of the best practices for the patient eligibility and benefits verification process.

Check if the plan is active.
Always quiz the patient about any impending or recent insurance changes.
Check if the patient has multiple insurances – primary, secondary and tertiary. Ensure that the patient has updated the Coordination of Benefits (COB) with each payer.
As a significant percentage of the population in the United States is aging, verify the Medicare coverage for patients who are above 65 years of age.
Understand if you need prior authorization or a referral for the specific medical service. If referrals or authorizations are needed, please obtain them and update the revenue cycle system.
Confirm if the patient's policy covers the procedure.
Some plans may stipulate the number of visits and time frame in which medical services can be delivered and have a ceiling on the benefit limits. The front office must obtain these details.
Specific services such as behavioral and mental health, substance abuse, and addiction may require a call to the insurance company. You may not be aware of these requirements and must refer to payer-specific guidelines.
Collect the payments for deductibles, copayments, and co-insurance based on the policy details. Pursuing patient collections can be tedious, and you must collect as much upfront as stipulated.
Collect additional information.

Social determinants of health are becoming an essential element of care delivery and promote healthcare equity and access. Characteristics such as race, gender, ethnicity, date of birth, preferred language, etc., are essential for Meaningful Use reporting. These characteristics are also crucial for health equity studies.

Outsourcing eligibility and benefits verification processes

An outsourced service provider can help you carry out eligibility and benefits verification processes. Their training processes help you get expert workers at reduced costs and reduce the workload on your revenue cycle team. Some of the benefits of outsourcing are:

Freeing up your staff's time to focus on other patient experience improvement and revenue cycle functions.
Speeding up time to care delivery.
Reducing denials and accelerated cash flow.
Reducing costs through labor rate arbitrage.
Well maintained policies and procedures.
Shifting the focus to denial prevention by reducing the number of eligibility and benefits related denials.

Eligibility and benefits verification company competencies

Efficient eligibility and benefits verification processes are essential for your organization's financial well-being. The process also accounts for the highest component of claim denials. You need to learn from each denial and constantly improve. Retain a company which can provide seasoned revenue cycle workers who can support your front-office staff with eligibility and benefits verification processes as well as comprehensive revenue cycle solutions to reduce costs and improve efficiency.

Additional Resources:

Medical Billing Wholesalers - https://www.medicalbillingwholesalers.com
_________________________________________________________
Melvin Miller is an experienced Chief Operating Officer with a demonstrated history of working in the healthcare industry for over 15 years, Satish, a.k.a. Melvin, has experience in team building, business development, Healthcare Information Technology (HIT), revenue cycle process training, US. Health Insurance Portability and Accountability Act (HIPAA), and Healthcare Management.

Billing/RCM

Addressing Revenue Cycle Labor Shortage With Technology and Outsourcing

Written by: Melvin Miller, COO

The labor shortage is currently one of the biggest issues across industries. Be it restaurants, hospitals, retail, hospitality, and manufacturing – take any sector and you will find that this is perhaps the #1 problem operations managers are facing.

In healthcare, the labor shortage is not limited to clinical roles but extends across administrative functions. Front-office staff, billers, coders, accounts receivable, denial management, and physician credentialing experts are in short supply.

If you look at the revenue cycle, lack of timely filing and follow-ups can increase denials and result in delayed cashflows. When your revenue cycle faces a staffing shortage for core functions, you tend to ignore the optimization functions such as quality assurance and underpayment reviews, which can unlock additional revenue opportunities.

The staffing shortage is aggravating problems for the hospitals, which were impacted already by the pandemic. Over the years, we have seen declining reimbursements necessitating revenue cycle operations to deliver the best financial outcomes, which requires deep healthcare and reimbursement process expertise.

With expert revenue cycle team members already in short supply and the mandate to get all employees vaccinated for COVID-19, hospitals and healthcare systems are losing employees due to resignations and terminations. Due to the shortage of clinical and non-clinical staff, many hospitals are on the verge of closing; in fact, many rural facilities have closed already. Further, the shortage has resulted in a fight for talent, which led to increased salaries and the cost of operations.

In this blog, we look at some of the strategies revenue cycle CFOs are deploying.

Cloud-based IT infrastructure

With the need to operate remotely, IT leaders are tasked with making mission-critical EHR and RCM platforms available anytime, anywhere. In most physician practices, the adoption of SaaS-based EMR/RCM solutions is increasing.

Process automation

Within both clinical and non-clinical revenue cycle solutions, the application of machine learning, AI, and RPA technologies are enabling revenue cycle leaders to combat the staffing shortage to some degree. Technology and automation can move routine, repeatable, labor-intensive tasks to the machines and reduce manual effort. For instance, claims status automation and the adoption of portals reduce call center workloads. When you free up people from mundane activities, they can focus on higher-value activities and have better job satisfaction.

Operational rigor

While all revenue cycle leaders talk about managing tighter operations, few have gone on to invest time and money in implementing workflow systems that help them measure, monitor, and manage the productivity of each employee. Transactional productivity improvements will, in the short term, lead to gains in financial outcomes.

Analytics for sustainable transformation

Usually, revenue cycle success boils down to strategic A/R management, i.e., understanding the patterns in denied claims, addressing root causes, strategic touches to claims in higher revenue brackets, and not allowing claims to fall into longer aging buckets. Revenue cycle analytics and adoption of industry-standard reporting can help RCM managers create the focus.

Outsourcing

Perhaps the #1 strategy that organizations are looking at is outsourcing, which gives them access to trained, certified labor across the nation. And with offshoring, you also get the benefits of cheaper cost structures. With the outsourcing and offshoring market now nearly two decades old, you can find service providers who have invested in process expertise and technology to help you get access to best-of-the-breed practices.

Optimizing costs to collect requires simultaneous implementation of pervasive change strategies

Across the revenue cycle operations, the questions that leaders need to ask are:

o What can you automate?

o What technologies do you need to invest in - workflow automation, analytics,
front-end tech?

o Where will you find the money to invest in new-age technology?

o Does this function need to be done onshore, or can you offshore it?

Cash is king. Leaving revenue on the table is a crime.

Faster cash flow cycles are critical to the survival of healthcare organizations. Address the problems such as revenue leakage and front-end processes sustainably to streamline operations.

Change the job content for your employees

Accelerating the adoption of technology and outsourcing can shift the focus of your employees to strategic tasks. The change in job content makes them feel empowered to impact the organization’s revenue cycle outcome, which is more satisfying.

Don’t just outsource. Choose your vendor partner well.

Plan along with your vendors, transition and stabilize operations, and then move the goal post for the vendor every quarter.

While you can take the short-term to address your revenue cycle issues, it is time for revenue cycle leaders to implement sustainable solutions. The labor shortage is not going away quickly, and reimbursements will continue to decline. Technology, operational rigor, and outsourcing are the only options you have. Choose well, plan well, and execute in style.

Additional Resources:

Medical Billing Wholesalers - https://www.medicalbillingwholesalers.com
_________________________________________________________
Melvin Miller is an experienced Chief Operating Officer with a demonstrated history of working in the healthcare industry for over 15 years, Satish, a.k.a. Melvin, has experience in team building, business development, Healthcare Information Technology (HIT), revenue cycle process training, US. Health Insurance Portability and Accountability Act (HIPAA), and Healthcare Management.

Billing/RCM

Key Revenue Cycle Trends for 2022 and Beyond

Written by: Melvin Miller, COO

Tech, investments, efficiency, patient experience, underpayment recovery, and coding automation are some of the themes that will drive the revenue cycle market momentum in 2022 and beyond. Coming at the back-end of a long period of adversity due to COVID-19 and an already challenging economic environment for hospitals and healthcare systems, we see a new wave of consolidation, invention, and innovation. In this paper, we discuss some of the trends experienced in health care.

TIGHTENING PROFIT MARGINS – A PANDEMIC RAVAGED REVENUE CYCLE TO BOTTOM OUT.

With hospitals operating on extremely tight margins, projecting cash flow and the ability to extract the maximum out of the revenue cycle is more critical than ever before. This will drive key technology and process innovation as revenue cycle leaders and managers strive to improve business outcomes.

Now, let’s look at the broad trends in each of the major revenue cycle processes.

Patient Access and Experience

Patient experience is now one of the key issues impacting the healthcare industry. There is a huge information deficit in the area of patient payments.

Patients question “How much should I pay from my pocket?” The answer has been surprisingly difficult to find. Patients must get quick and easy access to information about services performed and corresponding charges; the amount expected to be paid by their insurance company; and the out-of-pocket expenses they are expected to bear. It is important to include the aspect of the No Surprises Act, which complicates the situation for both providers and patients.

We anticipate patient access and experience to improve with new technologies that can project the costs they need to bear, improved omnichannel information availability, and improved payment plans. Patient financial services will go through a much-needed overhaul.

Prior-Authorization and Eligibility Verification

While great tech exists for information interchange, prior authorization and eligibility verification tech adoption have lagged because of a lack of standardized documentation and information exchange protocols. With clearinghouses now modernizing, there is new hope for API-driven information exchanges.

Autonomous Coding

Automation tech is seeing increasing adoption, and there is a general perception that coding, billing, and accounts receivable problems will be solved through automation. Artificial Intelligence, Machine Learning, and Robotic Process Automation technologies provide great promise to lower labor costs. Medical coding is becoming data-driven and autonomous with improved standardization through ICD-11 and a better combination of virtual scribing, Universal Medical Language Systems (UMLS), OCR, and natural language processing (NLP). While these are still early days, coding tech is yet to prove effective in finding discharges not fully coded (DNFC) and arresting revenue leakage.

A/R, Denial Management, and Appeals Filing

Accounts Receivable (A/R) status has moved from calls to portals. We see increasing relevance for chatbots using conversational artificial intelligence (AI) in A/R and denial management filing. Data structures can now power customized appeals filing as well.

Focus on the Front-End

Most revenue cycle leaders agree that they need to solve revenue cycle issues in the front-end rather than elongate the cycle and wait to address them in the back end. They recognize that they need to link prior authorization, revenue integrity, clinical documentation improvement, and denial management to accelerate their revenue cycle. The ability to quickly identify denial issues, determine root causes, and develop solutions to reduce these denials through an iterative model that focuses on denial prevention is considered the key to addressing revenue cycle issues.

Underpayment and Analytics

The Hospital revenue cycle is fraught with underpayment issues. Contract analysis and underpayment identification can help arrest underpayments. As the shift to more branded, national healthcare practices happens, performance analytics becomes a critical business function. Practice-specific analytics using standard measures and Key Performance Indicators or KPIs will enable accurate views of performance and drive corrective action.

Unprecedented Financial Activity – Private Equity (PE), IPOs, Mega-mergers, and More

“It’s like Woodstock,” as some revenue cycle dealmakers are saying. The role of private equity in healthcare, in general, and the revenue cycle business, in particular, has increased to an unprecedented level.

Entry of the big boys. The big boys, i.e., the large PE firms have made strategic investments in revenue cycle assets.
Technology-led investments. Some of the themes that PE firms are investing in include focused revenue cycle service providers and niche technology companies such as autonomous coding, patient experience, prior authorization, and large-scale offshore providers.
Investments in revenue cycle aggregators. It seems like if a company’s resume says revenue cycle, it is likely to attract many valuations. Further, larger companies choose to hit the primary market through an initial public offering. We are seeing increasing consolidation of revenue cycle service providers as well.
Provider side consolidation. There is an increasing amount of investment in consolidation on the provider side. The push to provide a branded healthcare experience through nationwide chains is driving investments in areas such as urgent care, behavioral/mental health, wellness-focused treatments, home healthcare franchises, etc.

In 2022, we anticipate the continuance of these trends and mega-mergers will be more of a norm than an aberration.

Telehealth Adoption

Spurred on by the pandemic, telehealth adoption is increasing. Not only does this mean a lower cost of care, but it also requires the adoption of new processes for patient monitoring and managing the revenue cycle.

Remote Working

The COVID-19 necessitated revenue cycle team members to adopt work-from-home models. It also required operations managers to be flexible and adopt technologies to monitor revenue cycle performance. We anticipate that hospitals and healthcare systems will look at remote working as the new normal and encourage a significant percentage of their workforce to work remotely.

Labor Shortage and Outsourcing

There is an acute shortage of qualified revenue cycle staff. Many community hospitals are concerned about the community’s response to outsourcing and offshoring strategies they adopt. At this time of rising hospital expenses and reducing revenues due to declining reimbursements, outsourcing, offshoring, and automation can help them contain costs and sustain profitability. If using a U.S. based company that offshores the majority of their work, have you checked with legal counsel regarding how this type of business associate can be held accountable under U.S. laws (such as HIPAA, False Claims Act, etc.)

Conclusion

There has never been a better time to be in healthcare – and these are the most challenging times as well. Both in terms of economic activity and innovation, 2022 is likely to set a scorching pace. Whether you are a healthcare system, revenue cycle services provider, or technology solutions provider, this year will force you to think innovatively, build new delivery frameworks, and create the revenue cycle of the future.

Additional Resources:

Medical Billing Wholesalers - https://www.medicalbillingwholesalers.com

_________________________________________________________

Melvin Miller is an experienced Chief Operating Officer with a demonstrated history of working in the healthcare industry for over 15 years, Satish, a.k.a. Melvin, has experience in team building, business development, Healthcare Information Technology (HIT), revenue cycle process training, US. Health Insurance Portability and Accountability Act (HIPAA), and Healthcare Management.

Auditing

Part 3: Audit Documentation to Avoid Potential Appeal Consequences

Written by: AIHC Blogger

This article provides educational information related to mitigating the risk of an unwarranted payer investigation. Only appeal claims when you have evidence and supporting documentation to substantiate your right to payment. This is the final article in a 3-part series on denials and appeals management. Read Part 1 entitled “Managing Denials Is Important to Good A/R Hygiene” posted March 22, 2022, and Part 2 entitled “Understanding How Payers Deny Claims.”

Audit Coding, Billing and Documentation for Accuracy

Insurance carriers and government contractors have the authority to review any claims at any time. Due to the huge volume of claims payers receive to process, deny and pay, they have implemented various methods to track providers to detect potential waste, fraud and/or abuse.

Providers may take documentation “short cuts” or feel overwhelmed with implementation of a new EMR (electronic medical record) system and clone or make documentation errors. It is important to detect any problematic areas prior to filing an appeal.

Lack of detailed supporting documentation submitted with an appeal can not only result in another denial, but also in “flagging” your practice as being high-risk on the spectrum of potential fraud and/or abuse. It can result in a situation where insurance opens an investigation or decides to initiate periodic audits on your claims and records. When you believe the payer is making the mistake, push back by exhausting all appeal rights allowed. If the payer, such as Medicare, performs an extrapolation, reducing each overpayment dollar through appeal can mean thousands less to pay back.

Utilize the information provided in the Part 2 article, such as ensuring the claim meets Medical Unlikely Edits, bundling, diagnosis and medical necessity guidelines. All modifiers should be appropriately appended and supported in the medical record. A great free modifier resource to share with you is the CMS Medicare Administrative Contractor (MAC) “WPS” learning center with on-demand training materials. Click here for the WPS modifier page (choose a region, the website will take you to the page).

Place of Service (POS) can be a “trigger” for an investigation. If the claim is coded POS 11 for the office, reimbursement can be higher than if the same service was performed at the hospital by the provider. Audit the POS to ensure this was coded correctly on the claim. A complete national POS code set and instructions are provided in CMS Internet-only Manual (IOM) Publication 100-04, Chapter 26, Section 10.5 at:

https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c26pdf.pdf

Is the date of service (DOS) correct? When the medical record date doesn’t match the date filed on the claim, you may have a difficult time arguing an appeal. Payers always require documentation for the date of service filed (and paid) on the claim. When the DOS is incorrect, accept the denial. If you have not passed the timely filing deadline, re-file the claim with the correct DOS.

Audit to ensure your organization has no excluded individuals employed

An example of a case settled in 2022 is Windham Eye Group, an ophthalmology practice paying $192,000 for employing an excluded practice administrator. Please make sure your organization routinely screens employees to ensure none are on the OIG exclusions list. Prior to appealing a Medicare, Medicaid, TriCare or other Federal Program claim, you should verify that your organization is compliant in this area (click here).

Evidence of Medical Necessity

Medical necessity includes frequency, duration, previous conservative treatment (that failed) and other factors. However, it also includes documentation of a supporting diagnosis.

The diagnosis coding on the claim is one of the first items insurance will review to qualify the claim as being “medically necessary.” Once the diagnosis coding passes through the insurance company edits, additional edits will then be performed against medical necessity criteria.

Diagnosis codes are an important compliance aspect of reporting medical necessity on the claim. They are also a large contributing factor for potential fraud and abuse when documentation does not support the diagnoses reported. Auditing the diagnoses on the claim to documentation is a critical review step to determine whether the claim should be appealed.

Diagnoses should be sequenced according to coding guidelines.
Each line-item on the claim should be linked to the appropriate procedure code.
Audit the code to ensure all characters are accurate.
Each condition reported on the claim must be documented in the patient’s chart.
Verify that the primary diagnosis is listed as “medically necessary” for the treatment provided.

Detect a Problem?

During the course of auditing or reviewing documents related to a denied claim, you may identify situations where further investigation is necessary. You may state it is simply a billing error. Errors made over and over in high volume or high dollar amounts will be interpreted as more than a simple billing mistake by payers.

Make careful consideration before appealing denials found on an investigational probe.

Obtaining legal advice before proceeding with an appeal may be necessary under certain circumstances.

Carrier SIU Situations

Insurance carriers have departments called Special Investigation Units or “SIU” with trained professionals carefully reviewing allegations of suspected fraud and abuse.

When a probe or investigation is initiated by a payer in writing or in-person, it is likely the investigators have already been speaking with your billing staff and patients to gather information to establish a case against you.

Can the investigators “get it wrong”? They can, sometimes!

There are times when investigators believe the situation is intentional (fraud) when the problem actually is being caused by lack of internal controls, auditing and monitoring by the provider. This allows errors to continue for prolonged periods of time.

When your office receives the results of the SIU (carriers) probe, the letter will provide guidance regarding ability to appeal. If you are given the option to appeal, have evidence of a strong argument to support that these claims should be paid. If you can’t meet the deadline to appeal, request an extension to buy more time to audit and properly prepare your appeal argument.

If your organization has a Compliance Officer and/or Certified Healthcare Auditor, you may want to bring concerning situations to his/her attention. Never file an appeal when you believe documentation may be evidence of fraud or abuse. You may need assistance from someone more highly trained in this area to determine this. If in doubt, check it out.

When speaking with your provider, Compliance Officer, Auditor or an attorney, the “short” list of rules and regulations which apply to medical coding, documentation and billing are listed below.

False Claims Act (FCA);
Anti-Kickback Statute (AKS);
Physician Self-Referral Law (Stark Law);
Social Security Act; and
United States Criminal Code.

The difference between “fraud” and “abuse” depends on specific facts, circumstances, intent, and knowledge. Examples of abuse can include such things as:

Billing for unnecessary medical services (lack of medical necessity);
Charging excessively for services or supplies;
Misusing codes on a claim, such as upcoding or unbundling codes;

According to the Medicare Integrity Program, activities which target various causes of improper payments are items such as those in the chart below.

The government's primary civil tool for addressing healthcare fraud is the False Claims Act (FCA).

Most FCA cases are resolved through settlement agreements in which the government alleges fraudulent conduct and the settling parties do not admit liability.
Based on the information it gathers in a FCA case, the Office of Inspector General (OIG) assesses the future trustworthiness of the settling parties (which can be individuals or entities) for purposes of deciding whether to exclude them from the Federal healthcare programs or take other action.

The OIG's efforts to curb fraud include:

Conducting criminal, civil, and administrative investigations of fraud and misconduct related to HHS programs, operations and beneficiaries;
Using state-of-the-art tools and technology in investigations and audits around the country;
Imposing program exclusions and civil monetary penalties on health care providers because of criminal conduct such as fraud or other wrongdoing;
Negotiating global settlements in cases arising under the civil False Claims Act, developing and monitoring corporate integrity agreements, and developing compliance program guidance.

Because OIG's assessment of the risk posed by a FCA defendant may be relevant to various stakeholders, including patients, family members, and healthcare industry professionals, the OIG makes information public about where a FCA defendant falls on the risk spectrum.

The five risk categories on the spectrum are defined below:

Highest Risk: Exclusion

Parties that OIG determines present the highest risk of fraud will be excluded from Federal healthcare programs to protect those programs and their beneficiaries. Excluded individuals and entities are listed in OIG's Exclusions Database.

High-Risk: Heightened Scrutiny

Parties are in the High-Risk category because they pose a significant risk to Federal healthcare programs and beneficiaries. This is because, although OIG determined that these parties needed additional oversight, they refused to enter Corporate Integrity Agreements (CIAs) sufficient to protect Federal healthcare programs. Parties in the High-Risk category that reached settlements since on October 1, 2018, or later are listed here.

Medium risk: CIAs or Corporate Integrity Agreements

Healthcare providers and other entities in the Medium Risk category have signed CIAs with OIG to settle investigations involving Federal healthcare programs. Under these agreements, parties promise to fulfill various obligations in exchange for continuing to participate in the programs.

Lower Risk: No Further Action

The OIG sometimes concludes that parties present a relatively low risk to Federal healthcare programs. As a result, OIG is not seeking to exclude them from those programs or require a CIA. OIG's cases against these parties are closed without evaluating the effectiveness of any efforts the parties have made to ensure future compliance with Federal healthcare program requirements.

Low Risk: Self-Disclosure

A party may disclose evidence of potential fraud related to Federal healthcare programs to OIG. The OIG believes that doing so in good faith and cooperating with OIG's review and resolution process generally demonstrates that the party has an effective compliance program. OIG works to resolve such cases faster, for lower settlement amounts, and with a release from potential exclusion with no CIA or other requirements. More information about OIG's self-disclosure protocol – click here.

This ends Part 3 for the denials and appeals article series. There is so much more to share with you, however, as you can see, filing an appeal involves various considerations and skill sets. Register, train and certify in Appeals Management - Online, On-Demand!

Billing/RCM

Part 2: Understanding How Payers Deny Claims

Written by: AIHC Blogger

This article provides educational information related to fighting unreasonable denials by working through a complex payer appeals process. This information is not all-inclusive and the article is a truncated version of Lesson 3 from our Certified Outpatient Clinical Appeals Specialist (COCAS^SM) training program. The complex Medicare appeals process is used to demonstrate the importance of appealing claims denied in an audit. Make sure to read Part 1: Managing Denials is Important to Good A/R Hygiene.

Audited by a payer?

Is your organization under a payer audit? Fight back by appealing unreasonable denials. But first, learn more about how a complex payer audit system works.

Understanding how a payer reviews and makes a payment determination will strengthen your ability to argue and defend your claim upon appeal. The learning objective of this lesson is to help you become familiar with the Medicare Claims Review Program (MCRP). This program monitors inappropriate payments. Other payers mirror Medicare’s program.

What is an “improper” payment?

These are reimbursements that should not have been made or that were made in incorrect amounts. According to the U.S. Government Accountability Office (GAO), improper payments have been estimated to total almost $1.7 trillion government-wide from fiscal years 2003 through 2019. Auditing and denying claims after the claims have been paid is “big money” for the government.

For example, the GAO states that they identified about $77.6 billion in financial benefits in fiscal year 2020—a return of about $114 for every $1 invested.
They also identified 1,332 other benefits that led to program and operational improvements across the government.
Most recently, GAO has been evaluating the largest response to a national emergency in US history, the $2.6 trillion COVID-19 response legislation, and making recommendations about how to improve its effectiveness in dealing with public health issues and the economy.

The Medicare Fee-for-Service Compliance programs prevent, reduce, and measure improper payments in FFS Medicare through medical review. A number of programs are provided to educate and support Medicare providers in understanding and applying Medicare FFS policies while reducing provider burden.

A Medicare contractor may use any relevant information they deem necessary to make a prepayment or post-payment claim review determination. This includes any documentation submitted with the claim or through an additional documentation request.

CMS' Center for Program Integrity (CPI) oversees Medicare medical review contractors. CPI conducts contractor oversight activities such as:

Providing broad direction on medical review policy
Reviewing and approving Medicare contractors' annual medical review strategies
Facilitating Medicare contractors' implementation of recently enacted Medicare legislation
Facilitating compliance with current regulations
Ensuring Medicare contractors' performance of CMS operating instructions
Conducting continuous monitoring and evaluation of Medicare Contractors' performance in accord with CMS program instructions as well as contractors' strategies and goals
Providing ongoing feedback and consultation to contractors regarding Medicare program and medical review issues

The Medicare Claims Review Program, or “MCRP,” involves both technical and clinical categories of denials performed by CMS contractors. It is a complex system, perfect to use as a teaching example! There are two categories of denials:

1. Technical Denial & Rejection
• This topic has been covered in previous lessons, but let’s review again!

o A technical denial is an error made when filing the claim, such as lack of appropriate coordination of benefits and filing to secondary insurance first. When a critical error gets through the scrubber, the insurance payer software may reject the claim due an error. Correcting these types of errors quickly and refiling the claim typically results in payment. These claims often “fall through the cracks” and can be suspended. Lack of tending to rejected claims can cause huge revenue loss for your organization.

2. Clinical Denial
• A clinical denial is the denial of payment by an insurance payor on the basis of medical necessity, length of stay or level of care. Special review of documentation, payer guidelines and often appealing the claim is required to obtain payment.

o When a payer sends an RFI (Request for Information), the payer is auditing the claim data against medical record documentation.
o Untimely response to the RFI will result in a denial.
o Sending inappropriate or wrong information to the payer will result in a denial.
o These types of denials can potentially trigger a larger audit, a probe, or an abuse or fraud investigation of your organization

CMS estimates the Medicare FFS improper payment rate through the Comprehensive Error Rate Testing (CERT) program. Each year, the CERT program reviews a statistically valid stratified random sample of Medicare FFS claims to determine if they were paid properly under Medicare coverage, coding, and payment rules.

Audits or claim reviews are conducted either prepayment or post-payment of the claim and typically fall under one of these categories:

Compliance to bundling edits (Medicare’s National Correct Coding Initiative or NCCI Edits)
Medically Unlikely Edits or “MUEs”
Comprehensive Error Rate Testing (CERT)
Recovery Audit Program
Medical Reviews (MRs)

National Correct Coding Initiative (NCCI) Edits

CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The Centers for Medicare & Medicaid Services (CMS) owns the NCCI program and is responsible for all decisions regarding its contents.

Most payers either use the NCCI edits or have a similar bundling edit system in place. Basically, bundling edits review codes on a claim to determine whether the items can be filed and paid separately or bundled into one code.

The claims scrubber software within your practice management system will analyze the codes on the claim and compare the information to the NCCI edits. Items that should be bundled will be suspended for further review. Your office cannot bill a patient for a service denied due to denied claims based on the NCCI edits.

These edits are updated at least quarterly and revised in your practice management system through updates to the software. Information about the National Correct Coding Initiative (NCCI) can be found in the Internet-Only Manual, Publication 100-04, Section 20.9 of Chapter 23 of the Medicare Claims Processing Manual.

When appealing NCCI edit denials, it is important to review the claim to ensure the appropriate modifier has been used. If not, review the documentation and appropriately append the modifier to the line item on the claim and submit your appeal with the documentation.

Modifiers allowed with the National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edit that can be used under appropriate clinical circumstances to bypass an NCCI PTP edit include:

Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
Global surgery modifiers: 24, 25, 57, 58, 78, 79
Other modifiers: 27, 59, 91, XE, XS, XP, XU

NOTE: Overuse of such modifiers just to get claims passed through the edits for payment can trigger an audit, probe or investigation.

Medically Unlikely Edit (MUE)

This audit feature analyzes a claim to determine if the appropriate number of units are being reported per line item. It is a unit of service edit for a Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code for services rendered by a single provider/supplier to a single beneficiary on the same date of service (DOS).

The ideal MUE is the maximum unit of service that would be reported for a HCPCS/CPT code on the vast majority of appropriately reported claims.

MUEs are designed to reduce errors due to clerical entries and incorrect coding. MUEs are adjudicated either as claim line edits or DOS edits.

If the MUE is a claim line edit, each line of a claim is adjudicated against the MUE value for the Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code on that claim line.
If the UOS on the claim line exceeds the MUE value, all UOS for that claim line are denied. If the same code is reported on more than one line of a claim by using CPT modifiers, each line of the claim is adjudicated separately against the MUE value of the code on that claim line.

For Medically Unlikely Edits (MUEs) that are adjudicated as claim line edits, each line of a claim is adjudicated separately against the MUE value for the code on that line. The appropriate use of Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) modifiers to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary UOS in excess of an MUE value.

24.G is the field on the 1500 claim being audited for MUE compliance:

These edits are updated at least quarterly and revised in your practice management system through updates to the software.

Comprehensive Error Rate Testing (CERT) Program

CERT contractors perform a complex medical review of the claim and the supporting documentation to determine whether the claim was paid appropriately according to Medicare coverage, payment, coding, and billing rules.

CMS calculates a national Medicare Fee-For-Service (FFS) improper payment rate and improper payment rates by service type to accurately measure the performance of the MACs and gain insight into the causes of errors. CMS publishes the results of these reviews annually.

The Medicare FFS Improper Payment Rate is a good indicator of how claim errors in the Medicare FFS Program impact the Medicare Trust Fund. CERT errors are listed by the following categories:

The Recovery Audit Program

Most hospitals and clinics are familiar with the “RAC” or Recovery Audit Contractor program – now referred to as the “Recovery Audit Program” by CMS.

RAC's review claims on a post-payment basis by auditing past Medicare FFS claim data for potential overpayments or underpayments and reviewing medical records when necessary to make appropriate determinations. When performing these reviews, Recovery Auditors follow Medicare regulations, billing instructions, National Coverage Determinations (NCDs), coverage provisions, and the respective MAC’s Local Coverage Determinations (LCDs). Recovery Auditors do not develop or apply their own coverage, payment, or billing policies.

In general, Recovery Auditors do not review a claim previously reviewed by another entity. Recovery Auditors analyze claim data using their proprietary software to identify claims that clearly or likely contain improper payments.

Medical Review Audits

Medical reviews identify errors through claims analysis and/or medical record review activities. Contractors use this information to help ensure they provide proper Medicare payments (and recover any improper payments if the claim was already paid). Contractors also provide education to help ensure future compliance.

One of the first items reviewed is a valid authentication or signature. Next, auditors typically review documentation for medical necessity; information to support units, laterality, diagnosis coding and supporting documentation such as signed orders or plan of care.

Learn more about clean claims, prompt pay laws, fighting denials based on medical necessity, appealing ERISA denials, the Medicare appeals process, and how to create an effective denials and appeals program – click here and become an Outpatient Clinical Appeals Specialist. Click Here to see if we have any upcoming classroom training camps!

Billing/RCM

Part 1: Managing Denials Is Important to Good A/R Hygiene

Written by: AIHC Blogger

Too many denied claims to manage? Practicing good revenue cycle management “hygiene” is important – but most don’t know where to start.

This article provides a basic overview of the importance of improving your appeals process to get denials overturned as it relates to overall revenue cycle management. This information is not all-inclusive and is for educational purposes only. We recommend formal training in denials and appeals management and encourage medical billing companies and practice managers gain better insight into accounts receivable (A/R) management through online training and certification.

Revenue cycle management includes tracking claims, making sure payment is received, and following up on denied claims to maximize revenue generation. Several metrics can help you determine whether your revenue management cycle processes are efficient and effective. The first metric is days in accounts receivable (A/R). Days in A/R refers to the average number of days it takes a practice to collect payments due. The lower the number, the faster the practice is obtaining payment, on average.

When a large number of denials are due to a single payer and in a short amount of time, conduct analysis of the situation quickly. Why? This could be an investigation initiated by the payer and may warrant additional assistance to evaluate. You need to know there is a problem and understand the underlying cause before you can resolve it.

According to the American Academy of Family Physicians (AAFP), a 5% to 10% denial rate is the industry average, but keeping the denial rate below 5% is more desirable. Automated processes can help ensure your practice has lower denial rates and healthy cash flow. For most practices, days in A/R should stay below 50 days at minimum; however, 30 to 40 days is preferable and achievable when your revenue cycle team works smart!

Know Your “Days in A/R”

When claims are filed but not paid, days in accounts receivable (A/R) will be higher than your internal historical benchmarks and likely higher than the industry standard for your type of specialty or practice. High days in A/R, or when receivables older than 120 days is greater than 12%, should trigger a signal that improvement is needed – fast! Most of the time improvement in the appeals process is required to avoid writing-off denied claims.

To get the most accurate picture of your practice’s financial standing, base your calculations on the actual age of the claim, i.e., the date of service, not the date on which the claim was filed or when it changes hands from one financially responsible party to another (primary insurance to secondary insurance; insurance to patient). This may mean contacting your vendor to adjust settings in your practice management system to create more meaningful A/R management reports.

How often does your Revenue Cycle Manager (RCM) run a credit balance report? Reconciling accounts with credit balances is the first step toward achieving maximum A/R hygiene. Credit balances are often a neglected aspect of the revenue cycle that can have serious negative effects. Credit balances left unattended can very quickly accumulate to a volume that impacts your accounts receivable reporting and may put your facility at risk for violating federal regulations or your insurance contracts. If your accounts receivable (A/R) reports include credit balances, your A/R will appear better than it actually is as the credits will offset balances due.

Next, calculate the practice’s average daily charges. Add all of the charges posted for a given period (e.g., 3 months, 6 months, 12 months). Then, subtract all credits received from the total number of charges. Next, divide the total charges, less credits received, by the total number of days in the selected period (e.g., 30 days, 90 days, 120 days, etc.). Next, calculate the days in A/R by dividing the total receivables by the average daily charges.

Review Aging Reports

Calculate A/R greater than 120 days using the oldest “buckets” in your aging report to determine how much and from what payers remains unpaid from the date of service to now. To calculate, divide the dollar amount of accounts receivable that is greater than 120 days by the dollar amount of total current accounts receivable, then multiply by 100.

Monitor Reports for Inappropriate Write-Offs

Are accounts reconciled and overpayments identified and handled properly? After careful review, are there adjustments made to accounts that have no paper trail or explanation posted on the account? Are there mistakes made with auto (or manual) posting of contractual adjustments? When your practice fails to distinguish between noncontractual adjustments and contractual adjustments, results may provide a misleading view of how well your practice collects the money it has earned. It can also be a sign of potential embezzlement. Categorizing noncontractual adjustments (e.g., “untimely claims filing” or “failure to obtain prior authorizations”), will help reveal sources of errors and identify opportunities to improve revenue cycle performance.

Managing the issues listed above should come first. Then, move on to calculating and improving your denial rate.

Know Your Claims Denial Rate

The denial rate represents the percentage of claims denied by payers during a given period. This metric quantifies the effectiveness of your revenue cycle management processes. A low denial rate indicates cash flow is healthy and fewer staff members are needed to maintain that cash flow.

A 5% to 10% denial rate is the industry average; keeping the denial rate below 5% is more desirable. Automated processes can help ensure your practice has lower denial rates and healthy cash flow.

To calculate your practice’s denial rate, add the total dollar amount of claims denied by payers within a given period and divide by the total dollar amount of claims submitted within the given period.

The lower the denial rate, the fewer revenue cycle workforce members are needed to manage receivables.

Analyze Denials Data

Root cause analysis or RCA may be helpful for your organization to avoid the “band aid” approach and resolve underlying contributing factors, such as inaccurate coding, documentation and/or billing practices. Revenue Cycle Managers are encouraged to obtain some training in compliance auditing. A good program should include basics in RCA and statistical analysis.

Use the Pareto Principle – the “80/20 Rule” to get organized and maximize revenue!

The 80/20 Rule means that in anything, a few (20 percent) are vital and many (80 percent) are trivial. Project Managers know that 20 percent of the work (the first 10 percent and the last 10 percent) consume 80 percent of your time and resources. You can apply the 80/20 Rule to almost anything, from the science of management to the physical world. The value of the Pareto Principle for a manager is that it reminds you to focus on the 20 percent that matters.

According to the Pareto Principle, of the things achieved during your day, only 20 percent really matter. Those 20 percent produce 80 percent of your results. Identify and focus on those things.

Don't just "work smart," work smart on the right things. It applies to denials management as follows:

The insurance companies you bill most – the top 20 percent of your payers are likely to contribute 80% of all insurance revenue. Focus on denials of those top 20 percent when starting your push-back appeals management program.

Take the denials representing those top payers; you are likely to find that 20 percent of those claims constitute 80 percent of the total dollar amount represented in the denial “stack.” Focus on those first.
Working the most commonly denied claims representing the higher dollar amounts FIRST with the objective of appealing before the deadline must be your goal.
If you must write-off denied claim balances in your system due to passing the appeal deadline, let it be the lower dollar amounts from payers you do not file frequently. This is not to say that these denials are less important, but decisions need to be made where to place energy and focus when resources are limited.
Track the amount or volume of write-off adjustments to request additional resources when warranted.

Be persistent, follow through and don’t back down when you know payment from insurance is warranted. Always keep track of problematic areas by payer. Create quarterly reports to analyze the number and type of denials per payer to check for “trends.” Meet with your provider relations representative, when possible, to discuss problem areas. Do not be afraid to take the appeal to the highest level allowed. Make your point with the insurance company in a professional manner. Be persistent and never back down when you know you are right.

Remember: An effective appeals management program, over time, will require fewer resources because the insurance companies are denying fewer claims.

Learn more about clean claims, prompt pay laws, fighting denials based on medical necessity, appealing ERISA denials, the Medicare appeals process, and how to create an effective denials and appeals program – click here and become an Outpatient Clinical Appeals Specialist. Click Here to see if we have any upcoming classroom training camps!

Billing/RCM

Update on No Surprises Act 2022

Written by: Joanne Byron, BS, LPN, CCA, CHA, CHCO, CHBS, CHCM, CIFHA, CMDP, COCAS, CORCM, OHCC, ICDCT-CM/PCS

As a result of the 2021 Consolidated Appropriations Act, several No Surprises Billing Act regulations went into effect on January 1, 2022, for providers, facilities and air ambulance services. The information below is not legal or consulting advice, but is provided as education and offers links to additional resources.

Starting January 1, 2022, the No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers.

This article is a follow up to the August 17, 2021, Sending “Surprise” Medical Bills to Patients? Think Again blog post related to the January 1, 2022, implementation of the Interim Final Rule (IFR) of the No Surprises Act. The new law provides consumers with federal protection from unexpected out-of-network medical bills.

Out-of-network charges are common in emergency care, where consumers don’t necessarily have a choice in where they go or who provides their care. These charges can also arise during non-emergency hospitalizations, where multiple providers may be involved in care. Even if a hospital participates in a patient’s insurance plan, specific providers, such as anesthesiologists or radiologists, may not. Consumers may have no idea that they’re getting care from out-of-network providers and no say in it either.

A news release from November 22, 2021, entitled New HHS Report Highlights How the No Surprises Act Will Prevent Surprise Medical Bills Faced by Millions of Americans highlights that millions of Americans with private health insurance experience some kind of surprise medical billing. The report states that surprise medical bills are relatively common among privately-insured patients and can average more than $1,200 for services provided by anesthesiologists, $2,600 for surgical assistants, and $750 for childbirth-related care.

The No Surprises Act establishes an independent dispute resolution process for payment disputes between plans and providers, and provides new dispute resolution opportunities for uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the good faith estimate they got from the provider. These don’t apply to people with coverage through programs like Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE. These programs have other protections against high medical bills.

Well, 2022 is here and it is time for EMS, hospitals and other emergency service departments to comply with the No Surprises Act. This can get complicated when meshing this Act with the Emergency Medical Treatment and Labor Act (EMTALA) imposing restrictions on obtaining patient financial or insurance status. The question – how can providers best manage EMTALA, Crisis Standards of Care (CSC), the pandemic and adhere to the new No Surprises Act?

First, it is important to have providers and other staff involved in patient care understand some of the more critical aspects of EMTALA. EMTALA requires Medicare-participating hospitals with emergency departments to screen and treat the emergency medical conditions of patients in a non-discriminatory manner to anyone, regardless of their ability to pay, insurance status, national origin, race, creed or color.

EMTALA is triggered whenever a patient presents to the hospital campus, not just the physical space of the ED but within 250 yards of the hospital. Patients who present to a hospital parking lot, sidewalks, and adjacent medical buildings are mandated to undergo EMTALA screening and stabilization. The provisions of EMTALA apply to all individuals (not just Medicare beneficiaries) who attempt to gain access to a hospital for emergency care.

The Centers for Medicare and Medicaid Services (CMS) defines a dedicated emergency department as “a specially equipped and staffed area of the hospital used a significant portion of the time for initial evaluation and treatment of outpatients for emergency medical conditions.”

EMTALA requires hospitals with emergency departments to provide a medical screening examination to any individual who comes to the emergency department and requests such an examination, and prohibits hospitals with emergency departments from refusing to examine or treat individuals with an emergency medical condition. The term “hospital” includes critical access hospitals.

This means, for example, that hospital-based outpatient clinics not equipped to handle medical emergencies are not obligated under EMTALA and can simply refer patients to a nearby emergency department for care. Typically, outpatient physician offices that do not have resources to stabilize critically ill patients are not required to perform a medical screening examination or stabilization before transferring the patient to an ED. In other words, patients who are part of an outpatient encounter are exempt from these EMTALA regulations. However, the No Surprises Act can still apply to services rendered by your provider.

When a patient has a health insurance Marketplace or individual health plan, the new Act applies as follows (this is a summary):

Bans surprise bills for most emergency services, even if rendered out-of-network and without approval beforehand (prior authorization);
Bans out-of-network cost-sharing (like out-of-network coinsurance or copayments) for most emergency and some non-emergency services. Patients can’t be charged more than in-network cost-sharing for these services;
Bans out-of-network charges and balance bills for certain additional services (like anesthesiology or radiology) furnished by out-of-network providers as part of a patient’s visit to an in-network facility; and
Requires that health care providers and facilities give patients an easy-to-understand notice explaining the applicable billing protections, who to contact for concerns that a provider or facility has violated the protections, and that patient consent is required to waive billing protections (i.e., patient must receive notice of and consent to being balance billed by an out-of-network provider).

Patient has no insurance? In most cases, a good faith estimate of how much the care will cost needs to be provided to the self-pay patient prior to rendering such care.

State Billing Laws Still Apply

The No Surprises Act supplements state surprise billing laws; it does not supersede them.

This new Act instead creates a “floor” for consumer protections against surprise bills from out-of-network providers and related higher cost-sharing responsibility for patients. So as a general matter, as long as a state’s surprise billing law provides at least the same level of consumer protections against surprise bills and higher cost-sharing as does the No Surprises Act and its implementing regulations, the state law generally will apply.

For example, if your state operates its own patient-provider dispute resolution process that determines appropriate payment rates for self-pay consumers and Health and Human Services (HHS) has determined that the state’s process meets or exceeds the minimum requirements under the federal patient-provider dispute resolution process, then HHS will defer to the state process and would not accept such disputes into the federal process.

Is Your Organization Prepared?

A violation of the No Surprises Act may result in a state enforcement action or federal civil monetary penalties of up to $10,000 per violation.

Know the plans your organization is in-network with – create a “grid” or listing for reference and keep it updated.

Know your state laws and when Federal laws supersede state rules. Contact your risk attorney through your malpractice insurance company for guidance which is obtained through no additional cost (part of the service you get when paying the insurance premium).

Identify eligible cases. The Act applies to post-stabilization care at out-of-network facilities until a patient can be safely transferred to an in-network facility. Nonparticipating providers and facilities may balance bill for post stabilization services only if all of the following conditions have been met, such as when the attending emergency physician or treating provider determines that the beneficiary, enrollee or participant:

Can travel using non-medical or non-emergency medical transportation to an available participating provider or facility located within a reasonable travel distance, taking into account the individual’s medical condition; and
Is in a condition to receive notice and provide informed consent.
The nonparticipating provider or facility provides the beneficiary, enrollee or participant with a written notice and obtains consent that includes certain content and within a specific timeframe and format outlined in regulation and guidance.
The provider or facility satisfies any additional state law requirements

Make sure revenue cycle workforce members understand EMTALA compliance and can identify out-of-network situations or when the patient is self-pay.

Implement an efficient and compliant method of providing a good faith estimate. The good faith estimate must include expected charges for the items or services that are reasonably expected to be provided in conjunction with the primary item or service, including items or services that may be provided by other providers and facilities.

From January 1, 2022, through December 31, 2022, HHS will exercise its enforcement discretion in situations where a good faith estimate provided to an uninsured (or self-pay) individual does not include expected charges from other providers and facilities that are involved in the individual’s care.

Download the CMS Model Notice and Consent forms.

Your revenue cycle department should have someone already trained to negotiate with out-of-network payers. The first step is to actively negotiate with insurance the highest reimbursement possible since you can no longer balance bill the patient. Are you utilizing Advanced Explanation of Benefits in plain language to provide good faith estimates? Track results – are your processes working?

Identifying No Balance Billing for Out-of-Network Emergency Service Definitions

Emergency services

With respect to an emergency medical condition, appropriate medical screening including ancillary services, medical examination and treatment required to stabilize the patient, and certain post-stabilization services associated with the emergency medical condition that are covered under the plan or coverage, unless certain notice and consent and other criteria are met.

Emergency medical condition

A medical condition, including a mental health condition or substance use disorder, manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a condition that places the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ.

Nonparticipating emergency facility

An emergency department of a hospital or an independent freestanding emergency department (or a hospital with respect to post stabilization services) that does not have a contractual relationship directly or indirectly with a group health plan or group or individual health insurance coverage, with respect to the furnishing of an item or service under the plan or coverage.

Nonparticipating provider

Any physician or other health care provider who does not have a contractual relationship directly or indirectly with a group health plan or group or individual health insurance coverage, with respect to the furnishing of an item or service under the plan or coverage.

Participating health care facility

Any health care facility that has a contractual relationship directly or indirectly with a group health plan or health insurance issuer offering group or individual health insurance coverage, with respect to the furnishing of an item or service under the plan or coverage.

Definitions Related to Continuity of Care When Provider Network Status Changes

Continuing care patient - an individual who:

is undergoing a course of treatment for a serious and complex condition from the provider or facility;
is undergoing a course of institutional or inpatient care from the provider or facility;
is scheduled to undergo non-elective surgery from the provider, including receipt of postoperative care with respect to such surgery;
is pregnant and undergoing a course of treatment for the pregnancy from the provider or facility; or
was determined to be terminally ill and is receiving treatment for such illness from the provider or facility.

Serious and complex condition definition:

in the case of an acute illness, a condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm; or
in the case of a chronic illness or condition, a condition that

a) is life-threatening, degenerative, potentially disabling or congenital; and

b) requires specialized medical treatment over a prolonged period of time.

Questions?

Send any questions about the provider requirements and provider enforcement to:

provider_enforcement@cms.hhs.gov

Resources

“No Surprises: Understand your rights against surprise medical bills” posted January 3, 2022, to inform patients regarding bills for emergency out-of-network services.
Call on your specialty organizations to provide specific guidance to help you through this new process. The American Medical Association (AMA) also posts helpful information for providers and offers an initial toolkit.
EMTALA Compliance Basics is a short course offered at a low price to help increase awareness for your workforce.
Train online in Outpatient Revenue Cycle Management to help increase expertise in outpatient medical billing complexities.
U.S. Department of Labor information page on No Surprises Act.
CMS “Ending Surprise Medical Bills” provides policies and resources - Review rules and fact sheets on what No Surprises rules cover and get additional resources with more information.
We recommend utilizing the National CMS webpage “Overview of Rules & Fact Sheets” and utilize the hyperlinks for more information.
Visit the American Hospital Association webpage “Guidance on No Surprises Act Good Faith Estimates, Patient-Provider Dispute Resolution Process.”

Page 1 of 8

First

Last