Even After Recent Medicare Cuts, How Much Money Are You Still Leaving On The Table?
Bryanne Johnson, CEO of Lincoln Reimbursement Solutions, talks with Paul about the recent cut to reimbursements that everyone in the industry is facing, and what it will mean for the future. She also discusses some of the ways that Outpatient Rehab Owners could be missing reimbursement opportunities.
Contracting and Credentialing with LRS
Here at Lincoln Reimbursement Solutions, we strive to become a dependable source of information when it comes to all contracting and credentialing needs. We recognize the importance of this process in jump-starting billing for your business.
At LRS, we know the burden of this administrative process and the time it takes to be able to complete this process from start to finish.
And when the time comes that you may feel the want to negotiate your current contracted rates, LRS has ample experience and expertise to take care of this need for you. Our employees will collaborate with you to gather all of the necessary information before sending these payors a detailed proposal letter to advocate for your practice and demonstrate why your business deserves a rate increase.
We know communication is key. At the end of every week, your company will receive a comprehensive update via email with a document exhibiting what LRS completed for the week and outlining next steps. In these updates, we will also ask you any questions we have regarding your current enrollments or any missing information needed to complete applications. These questions and concerns will also be communicated to you before the weekly updates so we may complete all applications in a timely manner.
Things You Should Know This Week
ICD-10 Code M54.5 Retired as of Oct 1
Some examples of more specific codes are:
S39.012: Low back strain
M51.2-: Lumbago due to intervertebral disc displacement
M54.4-: Lumbago with sciatica
M54.50: Low back pain,unspecified
M54.51: Vertebrogenic low back pain
If updating a diagnosis code within a plan of care, it's always a good idea to make the physician aware as well as your authorization team if the patient's plan requires authorization.
Effective Oct 1 Triwest Requires Referral Number on Claims
Submit claims with the following:
VA referral/authorization number AND one of the following:
10-digit Electronic Data Interchange Personal Identifier (EDIPI)
17-digit Master Veteran Index (MVI) ICN
Social Security number (SSN)
Last 4 digits for SSN with preceding 5 zeros (i.e., 00000XXXX)
Federal Employee BCBS Plan Issue
If you are receiving inaccurate denials for "duplicates", please know the APTA is actively working on this and will soon relay more information on how to resubmit these claims for accurate payment.
Blast Off Into Higher Revenues in 2022!
Establishing Your Insurance Contracts
One of the first questions a patient will ask a provider is, “Do you accept my insurance?” While this is a loaded question, you want to be able to tell the patient, “Yes, we accept your insurance and we are an in network provider.” Out of network is a scary phrase for patients and providers who are unfamiliar with insurance, therefore, we have placed an emphasis on a provider to become a participating/in network provider with many insurance networks. However, before you jump into and accept any and all contracts once an insurance panel opens, it is important that you take the proper steps to ensure you are setting your practice up for long term success.
1. Do your homework – review local insurances that are common in your area and research their policies, reimbursements rates, etc. Is the insurance a flat rate payor? Do they have a cap on modalities/units per day? What is their fee schedule and what percentage of their fee schedule are they offering to you in your contract?
2. Do you have a niche? Does your clinic have specialty equipment or do you have a certification that allows you to specialize in a certain area or treatment style? Any of these specialty services can set your practice aside from other providers and can give you an edge while negotiating a contract with a payor.
3. Are you in a densely populated area or are you the only provider in the region to offer a specific service to the insured in your area? This is also a great negotiating point when trying to get into an insurance panel or negotiating a rate with a payor.
4. Know your worth and do not settle! Advocate for your practice, our profession and the importance of the specialty services you can provide.
5. Show them the money – literally. Utilize outcomes, quality measures, net promoter scores, etc to prove your value to the insurances’ beneficiaries.
Credentialing and Recredentialing Your Locations and Providers
Once your insurance contracting is executed, the next step is to set up credentialing for each location of your practice and for each of your individual providers. While this process may seem daunting, remaining organized and in constant contact with each insurance company is key. Typically, the contracting and credentialing department at each payor can guide you on what documentation is needed in order to attach your locations and individuals to your established group contracts. This takes time and you should take into consideration that once a credentialing application is submitted to the insurance, it can take between 30 – 120 days before you receive a response. Some key points as you navigate through this process are:
1. Ensure accurate effective dates for your practice and your providers:
Be sure to inquire with the payer about backdating of effective dates. Some insurances may backdate to the date that the application was received. If you are expecting an approval, you can be riskier with these insurances and start to see patients for this payor once the application has been confirmed received.
Do not bill a new payer contract until you have confirmed the effective date. If you bill claims with dates of service prior to receiving your fully executed contract, you will surely receive denials that won’t uphold appeals. Knowing the effective date of a contract or a provider’s participation date is a critical piece of the credentialing process. This will ensure your claims are paid and avoid unnecessary denials.
2. Ensure proper time frame for credentialing:
Familiarize yourself with the time frames it takes to receive approval for credentialing and re-credentialing. These time frames vary widely payor to payor.
Ask for confirmation of receipt when submitting an application. Follow up every two days until confirmation is received.
After you’ve received confirmation of receipt, follow up every two weeks until approval is received.
Keep a spreadsheet to organize progress, follow up intervals, and responses.
Set reminders to ensure no follow ups are missed!
Always get a reference number for every single call you make to an insurance company!
3. Ensure billing and credentialing departments are communicating:
Your billing and credentialing departments should have a solid process in place for communicating credentialing status’ and how that directly affects the submission of claims.
It is essential that your credentialing department shares all crucial information with your billing department, including: pending, approved, and terminated credentialing status’; claims that need to be held and when those claims are okay to be submitted; and contract intricacies to ensure that the EMR and claims reflect the contract details.
Establishing Your Fee Schedule Within Your EMR
This is an arbitrary number that gives you an idea of what your reimbursement per visit will be for each date of service rendered. It is usually marked up from the Medicare fee schedule. You want to mark it up so that you are able to capture all different payor and payor sources allowed amounts. Generally, PIP/Auto insurances will pay more than the Medicare fee schedule. But if you bill these claims at the Medicare fee schedule, then that is what you will be reimbursed.
If you need to change your fee schedule for any reason it is good to take note that your payment percentage will also change. Your payment percentage is a historical calculation of your paid claims divided by the amount that you charged for those claims. If you track paid percentage and disallowance on certain codes, once you change your fee schedule, that percentage will also change. This is something that is always okay to do, however, you will not be able to compare it to your historical data. Ideally, it is crucial to set this up properly from the start and then monitor your paid percentage closely to look at trends in your reimbursement. This is a key metric to monitor the health of your practice.
Setting Up Your Payors and Payor Rules Within Your Documentation System
Make sure you are establishing each payor with the correct payor guidelines.
AMA vs CMS
The main difference under AMA guidelines is that the AMA does not calculate the total time or cumulative time of a treatment session. They consider each unit and each unit must be at least 8 minutes in order to bill for it. This is why some people call the AMA guidelines the “Rule of 8’s.”
Per CMS, in order to bill one unit of a timed CPT code, you must perform that associated modality for at least 8 minutes. Medicare calculates the total time spent in a treatment session and divides by 15 to figure out how many units are rendered on a given service date. If eight or more minutes are left over, you can bill that time as an additional unit. If 7 or less minutes are left over, you must drop those minutes and not bill for them. Simply put, Medicare takes total time and uses the chart below to determine how many units were rendered on a particular treatment session.
8-22 minutes : 1 unit
23-37 minutes : 2 units
38-52 minutes : 3 units
53-67 minutes : 4 units
68-82 minutes : 5 units
83 minutes+ : 6 units
2. Each payor also has a specific set of rules around modifiers, evaluations, authorizations, etc. Make sure these items are set up properly from the start to avoid denials, patient balances and messes on the back end!
The Front End Basics
Insurance verification and authorizations play an essential role in avoiding denials and patient ineligibility for services. They are also a key component in your customer service.
While it is the patients’ responsibility to know their benefits, we are all aware patients often do not even know what a deductible is - let alone how much they have remaining on it. If you do not present this information at the time of service, you could be dealing with an angry patient down the line after he or she receives a statement.
What Does the Insurance Verification and Authorization Process Entail?
There are several things that should be obtained when an insurance verification is completed. These include: payable benefits, co-pay amounts, co-insurance amounts, deductible amounts, effective date of plan, additional coverage details, whether authorization (or prior authorization) is required, confirmation of claims address, the patient's yearly maximum, etc. While some insurances allow you to check benefits online and they can be completed fairly quickly, other insurances require up to an hour (!!) spent on the phone to obtain benefits. Ensuring this process is done correctly on the front end will save your team a significant amount of time and resources on the back end to avoid denials as well as make your practice more money to get claims paid the first time around.
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As we continue to navigate through everchanging reimbursement models, new edit changes and constant fluctuations of authorization requirements, it is important to continue to maintain, manage and measure the health of your practice to ensure proper steps were taken and are continuing to be completed. Below are some key metrics to look at on a quarterly basis to take a quick glance if the above is being completed properly.
Denial/First Pass Payment Rates
How many denials are you receiving and how many claims are paid on the first submission? Many factors go into these metrics including accuracy of patient intake and registration information, correctness of insurance verification and authorization information, and how claims are being submitted per payor guidelines. A very efficient practice will have a denial rate under 5% and a first pass claim rate higher than 95%.
Percentage of Receivables over 120 Days
How quickly are you collecting the money you are owed? You should be aiming for less than 10% in the 120+ aging bucket. There are always going to be issues with specific claims but a healthy practice has about 75% of their AR in under 60-days outstanding.
Payer Mix/Expected Revenue per Payer per Visit
Who are your top 5-10 payers? What are they paying you per visit? Your overall cash flow is very dependent on your payor mix and what each payor is paying you per visit or per unit on average. This is an important metric every practice should monitor closely. Maybe it is time to try to renegotiate contracts, to consider going out-of-network with some insurances or maybe it’s time to use your marketing dollars more strategically.
These are only a few of the metrics you should be reviewing on a monthly basis, however, they will give you the big picture overview of how your practice is doing.
Utilizing Data to Engage Our Stakeholders
How do we engage our most important stakeholders with the data that impacts and matters most to them?
Stakeholder #1: The Employee
Have your employees take part in the budgeting process. Empower them to have a voice in what is and is not attainable. Let them see how each scenario impacts the bottom line.
Encourage your team to provide input on establishing tangible targets, such as:
Number of new patients
Number of visits
Visits per new patient
Visits per day/hour
Units per day/hour
Conversion ratio
Net promoter score
First pass payment/clean claims percentage
Including your entire team, clinical and administrative, in these initial conversations helps them understand the “why” behind what is expected of them. It will enable your staff to communicate “objectively” as opposed to “subjectively” and will alleviate friction down the road when therapists appear to be overbooked or there are too many new patients to be scheduled.
Private practice owners fear that our staff will frown upon the sharing of operational and financial numbers. What we have seen is practices that focus on clinical excellence and patient-centered care are able to create a culture in which everyone feels like part of the business team. Create a dashboard or a spreadsheet that enables your employees to view these critical metrics against a target on a weekly basis. The clinic director can share these numbers with all staff in a “huddle” meeting, gathering briefly to discuss these key measures.
If we present accessible data and seek input from staff members, employees will be motivated to participate in these discussions. For example, front desk employees will see the financial impact of missed authorizations, upfront co-pay and deductible collections, as well as common denial trends. A position-based incentive program can be used to further motivate employees to meet or even exceed targets. Our experience is that employees will feel invested in these metrics if a portion of their compensation is based on performance in these key areas of the business.
Stakeholder #2: The Patient
Provide your patients with accurate expectations of their insurance coverage at the very first visit. Walk the patient through their plan of care so they know how many visits and copayments to expect. Stress the importance of completing their plan of care and provide solutions to any potential cancellations, including the benefits and effectiveness of telehealth as an alternative when they are not able to attend an in-person visit.
Does the patient require an authorization? Keep them engaged with their insurance plan and benefits. Track this diligently behind the scenes and let the patient know how hard you are working to obtain this for their care. A robust tracking process will also minimize unauthorized visits.
Empower your patients with their outcome data. Share their baseline results as well as where they should be at the end of treatment. Make their progress tangible – give them a “report card” listing the outcomes you are measuring so they can record them and really “see” their progress. They will be motivated, and you will be demonstrating the value of your care. Do the same with home exercise programs. There are many programs and applications that record patient participation so both therapist and patient can monitor compliance and celebrate accomplishments. An interactive platform that summarizes activity data and makes it meaningful will motivate patients to engage and invest in their treatment.
Stakeholder #3: The Physician
Track the number of referrals and converted referrals from each specific physician.
Compare trends between your liaison team and your scheduling team. Are there issues with obtaining referrals or issues with converting referrals? Analyze cancellation trends per physician. Follow up with physicians about unsuccessful referrals, and identify those patients who either never scheduled or did not attend their evaluation. Make this data meaningful to the physician by demonstrating the missed opportunity to bring their patient back to optimal health. Depending on the size of your practice, these metrics and marketing activities should be tracked in a Customer Relationship Management software.
For each referral source, use a tool that not only tracks the number of referrals sent in a given month, but also compares this metric to the same month last year, as well as year to date referrals. This data will be powerful for your liaisons and clinic directors, focusing them on key referral sources that have trended up, or down, and providing them a high level of certainty on who they should be targeting.
Engage with physicians by providing your outcome tools and data. Package your patient outcomes to make the most impact. For example: Patients who come to us with diagnosis X achieve a better outcome as compared to the local and national market trends, inserting your data as applicable. Meaningful data is not just numbers and charts …. share and celebrate their patients’ success stories using a tablet or phone. A picture or video is worth a thousand pieces of data!
Stakeholder #4: The Community
There are many tools and resources that make it easy to engage with your community. Keep Google My Business up to date and ensure you are visible on Google searches. Conduct geofencing and geo-targeting campaigns. Monitor visits and clicks in order to track your ROI and success rate, which generally vary across regions.
Staying active on social media can increase interest and drive visits to your practice. Post patient success stories. Recognize community members. Highlight community events and initiatives you participate in and support. Demonstrate your expertise by posting health promotion educational sessions that tie into the services you provide. Share your net promoter scores.
Be sure to analyze patient data to determine your “target audience” in your community. This can relate to gender, age, specific injuries, and any other relevant factors. What outcomes have you achieved for these patients? And where do these patients spend time in your community? Now you can focus your marketing efforts on specific groups of patients you have had the most success treating in the past. Use this methodology to determine your next “niche” program. The group of patients you have been “best for” in the past is often the same group that will be the basis for a new venture.
Each stakeholder plays an integral role in the success of your practice, as well as the improvement in the lives of your patients. Make arming your stakeholders with meaningful data a priority and publicize outcomes against the internal standards you have set.
Your team will be happier and more productive if they have concrete, measurable goals, and are incentivized to exceed those expectations. Your patients, physicians and community constantly need to be reminded of the value of physical therapy in general and your practice in particular. If you engage and educate your stakeholders with meaningful data-driven analytics, each one will appreciate exactly how their efforts contribute to the success of your practice.
The Pathway to Payment
Step #1: Credentialing
The first step along the Pathway to Payment is to ensure that your providers are credentialed and participating with multiple payors. Becoming a participating provider (“PAR”) with an insurance has its perks and patients generally are fearful of the terms “out of network” when they are selecting which providers they want to use.
The credentialing process may seem daunting at first - especially with the different forms, applications, provider numbers, and licensure documentation you have to provide, not to mention the processing time for your application. But, this is arguably the most important step on a long process to getting paid.
If you have multiple locations within your practice, each one needs to be credentialed with each insurance you want to be a participating provider with. Each individual provider within your practice should also be credentialed with those insurances to avoid delays in completing documentation due to needing a co-signature.
Step #2: Insurance Verifications and Benefits
Once your practice becomes a participating provider with these insurances you can start accepting patients with those insurances. One of the perks of being PAR with these payors is that you can have access to online portals that are available. These portals are extremely convenient and give you access to a multitude of resources - benefit information being one of them.
Many of these insurances can be found on hub portals such as Availity, but other insurances have their own portals such as state Medicaid programs and Medicare. Setting up these portals is generally a simple process where you have to register your NPIs and TINs for each location, create a user login and password, then verify your information.
One of the resources on these portals lets you check benefit information for policyholders. This will help your practice as well as the patient have a better understanding of patient responsibility and cost-share amounts for the services you are providing. The most important items to confirm while checking benefits are:
Authorization requirements (be sure to confirm if this is handled by a third party vendor rather than the insurance)
Copays
Coinsurance
Deductible
Out of pocket expenses
Visit limits (this is not the same as authorized visits)
After you have verified the benefits and confirmed accumulations for each cost-share item, provide this information to the patient prior to him/her starting treatment. This is best done by completing a financial responsibility sheet or insurance benefits information sheet to include in the patient’s intake paperwork. The patient should attest to the benefits information and acknowledge that he/she is aware of the potential patient responsibility throughout the course of treatment.
This ensures there are no surprises to the patient or to your practice once the claims process. If the patient has a copay, you will be aware of that and can collect the copayment at each visit, rather than waiting to collect it once the claims process and your chances of collecting are significantly reduced once the patient leaves your clinic.
Step #3: Authorizations
Some insurance plans require authorization - and depending on the insurance this may be referred to as clinical submissions, precert, medical necessity review, etc. - so it’s important to understand each payor and the terminology they use when requiring an authorization. If this information is not on the portals then someone must call the insurance to confirm the authorization requirements. During a time where technology has consumed almost every aspect of society, a good old fashioned phone call to speak to a representative about the authorization is always worth making.
Online Portals / Requesting Authorizations
This information should be collected during the benefits check back at Step #2. The process for obtaining authorization should also be obtained during the benefits check. This is also a feature on some online portals where the benefits information is located, however, if the authorization is handled by a third party vendor, then you need to contact that vendor to have your processes in place for submitting these authorizations. These third party vendors often also have online portals to submit and check the status of authorizations.
Tracking System
There needs to be a diligent system in place to track and monitor your patients who require authorization. If the authorization is required before the eval, then your team needs to ensure the necessary steps are being taken to get the auth requested prior to eval date. There are several nuisances about authorizations that are imperative that you are aware of and you should always confirm which CPT codes require authorization.
Tracking and submitting authorizations will avoid losing reimbursement for services rendered due to missing authorizations. Your entire team should be involved in this process so they understand the “why” behind the importance of diligent tracking and requesting authorizations when they are needed. Once the authorization is approved and can be tracked in your billing software your team should be able to run reports and view patient charts to see when the authorization expires/the patient needs more visits.
Retroactive Authorizations
If an authorization is missed the next option is to attempt a retroactive request for authorization. Many insurances do not allow retroactive authorizations, but again, this information should be obtained during the initial benefits verification. If the retroactive authorization is denied, the final resort is appealing for medical necessity.
Step #4: Submitting Claims
This step is one of the most satisfying steps along the Pathway to Payment. It combines all of your efforts from the previous steps and sends them off to the insurance for processing. This step is also the intermission step where we wait for the next step.
Many payors have transitioned to electronic submissions of claims. Every billing software should have the option to physically print these claim forms and mail to the insurances as well as an option to set up EDI for electronic submissions for quicker turnaround times for claims processing.
The two key focuses at this step are 1) ensure each payor is set up correctly and 2) be aware of timely filing deadlines.
When the payor settings are incorrect or do not coincide with the information the payor has on file for your location is when you run into denial issues which ultimately put you at a race against the clock to have claims resubmitted. Getting claims out the door is at its core the purpose of the revenue cycle, but getting claims out the door correctly the first time is what the focus should be on.
Common issues with claim submissions include submitting claims to the wrong physical address, having the wrong EDI set up for electronic claims, missing information on the claim forms, and missing timely filing deadlines. All of this information is easily attainable and should receive a high level of attention from the beginning. Once these payors are set up in the billing software you will likely not have to edit them again.
Take time to refine your process and ensure everything in your billing software is set up correctly before mass submitting claims. Once the claims are out the door - we wait.
Step #5: Accounts Receivable
At this point, we are about 30-45 days out from the first time a patient entered your practice for services. This step is also very satisfying because you see the hard work from steps #1-5 pay off - literally.
Overall, you should have a processed mapped out and strategy in place on how you will handle these sets of aged claims. The AR Team needs to be aware of nuisances across insurances as well as timely filing deadlines.
These items should be tracked and handled in an efficient and timely manner.
0-30 Days Aged
Aging reports for claims should be run in a timely manner starting with claims that are 0-30 days aged. Many of these claims will still be processing but it is important to keep track of them because 30 days quickly turns into 90 days if you are not conscientious of the aging process and running the aging reports.
30-60 Days Aged
Claims that have aged 30-60 days should be a primary focus since this is where you will catch any denials or rejections from either the clearinghouse (if claims were submitted electronically) or the insurance company for invalid/incorrect/missing information on the claim forms. This is a crucial hurdle in the process that can be remedied and the potential to collect on these claims is highly likely since this is usually still within most insurances’ timely filing limits.
60-90 Days Aged
This aging bucket is where you should be concerned with the reason for these claims aging out this far. Did the insurance pay and now you are waiting for the patient to pay? Did you miss a denial? What next steps need to be taken to resolve these claims?
90-120 Days Aged
This group of aged claims should sound the alarm for your AR Team. These claims either fell through the cracks of the previous aging buckets or you are waiting for payments from patients. At this point, all hands should be on deck to get claims reprocessed at the insurances - if timely filing limits allow this - or patients need to be called about their outstanding balances.
120+ Days Aged
Any claims outstanding at insurances at this stage should be addressed immediately to resolve the issues. If there is no other remedy for the claim, it will likely result in a write off.
Any patient balances that have aged this far should also be addressed immediately by making final calls to collect on the outstanding balances before they are sent to collections.
Step #6: Denials and Appeals
The final step on the Pathway to Payment is addressing any denials that are discovered in the AR process at step #5. Common denials include missing authorizations, invalid member ID, missing provider information, and missing clinical documentation. Each of these can be easily avoided at their respective steps along the Pathway, which is why it is important to take your time at each step to ensure everything is handled correctly before going to the next step.
If the claims are returned for denials, some of the issues can be resolved by resubmitting the claims with corrected information and/or documentation.
Other claims may require additional work such as filing an appeal if they are denied for medical necessity or missing authorization. The appeals process for each insurance is different in that some require forms to be completed while others allow for a more informal request for appeal.
Either way, all insurances have timely filing deadlines for these appeals and they should be strictly abided by. This is your last chance to get paid on claims.
Painless Credentialing
At LRS, we promise to guide your business through the credentialing process from the initial application to final approval. Our goal is to improve the quality and efficiency of the credentialing process for you and your clinic.
LRS works to reduce the administrative burden that is placed on the medical practice and instead allows you to focus on providing quality care to your patients.
If it's 1 provider or 1,000 providers, we're here to help. Let's chat!
Tracking A Physical Therapy Practice’s Success
In the physical therapy industry, there is always discussion around metrics and key performance indicators (KPIs).
Data is power when it comes to reimbursement, making business decisions, and standing out from referral competition. The more real-time data an owner has on the health of the practice, the more they are able to translate metrics into actions whether it be increased marketing, more strategic scheduling, or practice hiring decisions.
Now, more than ever, it is time to celebrate a practice’s success through the use of value data and KPIs. There are many ways to track a practice’s operational, financial, and consumer successes. Here are several of these key functions that are important to outpatient therapy practices:
VERIFICATION OF BENEFITS
It is critical to collect any patient responsibility for a visit when a patient is physically in the practice. The chances of collecting a copay decrease 20% immediately after a patient walks out the door.1 Given the slim margins that practices operate on, the patient responsibility portion of the visit can be the difference between making a profit and losing money. The best way to be able to collect up front is to ensure there is an accurate verification of benefits information available. The patient can be made aware upfront how much they will be paying out of pocket and have it paid in the office instead of sending patient statements after the plan of care is completed. This is an easy way to show a front desk staff member’s success by tracking the percent of copays collected.
CONTRACTING AND CREDENTIALING
Understanding insurance contracts and how they are reimbursed is a major key in operating a practice. Knowing that a payer always requires an authorization before a visit could ultimately save significant money across a plan of care. Knowing that certain carriers only reimburse four units/visit and other nuances of payer contracts can help a practice schedule patients more appropriately based on the payer’s guidelines. Another key metric under contracting is revenue/visit and what percentage of the fee schedule a practice is receiving from each carrier. This metric could lead to additional needs to renegotiate with insurance companies.
Another important front-end step to ensure success is an efficient credentialing process. Insurance companies make this a significant burden for providers by requiring every clinician be attached to the clinic’s NPI. This is a critical piece to the new hire onboarding process that involves the front office, clinical and billing departments communicating and operating on the same page. By having a successful process in place, practice owners can set their entire team up for less headaches and more paid visits.
CANCELLATION AND NO SHOW RATES
Given COVID-19, this metric is currently looked at differently, but this is still a reflection of care provided. Anytime a patient cancels or does not show for an appointment, it is costing the practice time and money and is costing the patient the benefits of therapy. However, given the inevitably of cancellations, there should be someone at the practice dedicated to filling open slots on the therapist’s schedules when this occurs.
The cancellation metric also highlights the therapist’s success in explaining to their patients the importance of completing plans of care. A high rate of unexcused cancellations can be a sign that a therapist is not effectively selling the importance of their goals for their patient.
VISITS/FULL-TIME EQUIVALENT/DAY
This will tell on average how many visits a full-time therapist is seeing per day. This doesn’t matter who the provider is, what the diagnosis of the patient is, whether or not the patient is being seen in the pool or on land. It provides an overall average. The intended goal for this number may differ depending on those items listed, however, this number alone will determine if the practice is staffed appropriately according to the current caseload and volume of patients.
UNITS/VISIT
This will tell on average how many units a therapist is delivering per visit. This number will tie to multiple criteria based on clinical outcomes but it will also tie into the practice’s financial outcomes. This is a good way to have a pulse on the care delivery model from a high level overview. For instance, if the outcomes score of a clinic is lower than the national average and the units/visit are approximately 2/visit, that may determine a different care delivery model is needed.
THERAPIST AND PATIENT OUTCOMES
Outcomes data is essential when marketing the success of a practice, why therapists should want to work for the practice, why physicians should refer their patients to the practice, and why payers should pay the practice at increased rates. In a value-based care model, a practice needs to be able to show why and how they measurably outshine the competition.
How effective is the therapy team at getting patients better? This is why clinicians go into physical therapy – they want to heal! Tracking this and being able to educate staff on raw numbers can make a difference in a practice’s bottom line and with a therapist’s mindset in how they treat their patients. There are tools that are able to drill down on effectiveness under each diagnosis. By using tools, an owner can evaluate their therapists more objectively. This can lead owners to determine that providers may need continuing education on best practices and treatments.
Outcomes data is also something that can be marketed to specialists and referring physicians. This also shows a practice’s value across the continuum of care and the efficiency of the plan of care to these referral sources and to the patients they are referring to for therapy.
This is also data a practice can use when trying to renegotiate payer contracts. If a practice can show that their outcomes are better than average, they can argue that they should be paid at higher rates. Physical therapy is constantly fighting decreased reimbursement. By providing quality and efficiency data, a practice can guard against these fights with actual data on how they are making a difference in a patient’s lives.
NET REVENUE PER VISIT
This is the ultimate metric that tells a practice if and how they are going to make a profit. To calculate this number, a practice needs to consider everything that goes into the overhead of running the business and then divide this number by the number of patients seen in a given month. This number is the cost per visit. If the cost per visit is higher than the revenue per visit, a re-evaluation of the operations of the practice are likely needed. Once a practice has a good baseline of how these metrics average, they can set business goals, make hiring decisions, and strategically think about their payer mix and referral sources.
NET PROMOTER SCORE AND PATIENT SATISFACTION
A practice’s growth is tied to how happy a patient is when they complete their plan of care. Patients should be treated as though they are family. A large percentage of referrals at clinics are return patients. These patients return because they are happy with the care they received and these patients will also refer their friends and family for services. There should be consistent marketing to previous patients for this reason.
While a practice can do everything they can to create a positive patient culture, there will always be those who are unhappy with the care they received. In the same vein as following-up with patients who scored their experience higher, it is important to follow-up with those who did not so a practice can learn how they can be better for the future.
A well-monitored clinic will create happy patients, positive clinical outcomes, and increased financial success. The metrics discussed here are just a few of the ways a practice can highlight individual successes and plan for the future. However, it is also a critical time that as an industry, therapists and practice owners come together to share their successes with payers, referral sources, and government agencies to guard against declining reimbursement levels and other challenges that are facing outpatient therapy. Stay healthy and advocate for our industry!
Medicare Temporary Claim Hold
As we wait for Congress to vote on the legislation to hold off on the 2% Medicare sequestration, CMS has announced that all Medicare claims will be placed on hold starting with dates of service April 1, 2021. This will help the MACs reprocess claims if Congress decides to pass legislation to extend the sequestration reduction.
We will keep you posted as we learn more!
The Difference Between a Re-Eval and Progress Visit
When it is it appropriate to bill 97164?
Therapists often get confused between when they should bill a progress note and when they should bill a re-evaluation. However, there are extremely strict guidelines when it comes to using each code.
Re-evaluations are not routine and shouldn’t be billed routinely. Progress notes are routine and are completed at every 10th visit or every 30 days (whichever comes first).
According to Medicare, “Routine re-evaluations of expected progression in accordance with the plan of care, either during the episode of care or upon discharge, are not considered to be medically necessary separately billable services.”
When medical necessity is supported, a re-evaluation (97164) is appropriate for:
A patient who is currently receiving therapy services and develops a newly diagnosed related condition e.g., a patient that is currently receiving therapy treatment for TKA. During the episode of care, the patient develops wrist pain. The clinician determines that the wrist pain is due to use of a walker which the patient is using as a result of the TKA. In this scenario, the wrist pain is a condition that is related to the TKA. Therefore, it is reasonable for the clinician to provide a re-evaluation of the patient due to this related condition.
A patient who is currently receiving therapy services and demonstrates a significant improvement, decline, or change in condition or functional status which was not anticipated in the plan of care and necessitates additional evaluative services to maximize the patient’s rehabilitation potential.
If it is appropriate to bill a re-eval, what should it include?
On November 10, 2016, CMS published the following information regarding the re-evaluation code:
97164 – Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and a revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome.
It is important to note that 97164 can be billed and bundled with other 97xxx codes with the addition of the 59 modifier to indicate the service is separate and distinct. It is also important to note that whenever a 59 modifier is on the claim, we need to indicate in the notes that the services are separate, distinct and medically necessary.
Still confused or have additional questions? Contact LRS at inquiries@lincolnrs.com and we can get them answered for you.
The Pathway to Payment and all the Bus Stops Along the Way
Bus Stop #1: Credentialing
The first stop along the Pathway to Payment is to ensure that your providers are credentialed and participating with multiple payors. Becoming a participating provider (“PAR”) with an insurance has its perks and patients generally are fearful of the terms “out of network” when they are selecting which providers they want to use.
The credentialing process may seem daunting at first - especially with the different forms, applications, provider numbers, and licensure documentation you have to provide, not to mention the processing time for your application. But, this is arguably the most important stop on a long road to getting paid.
If you have multiple locations within your practice, each one needs to be credentialed with each insurance you want to be a participating provider with. Each individual provider within your practice should also be credentialed with those insurances to avoid delays in completing documentation due to needing a co-signature.
Bus Stop #2: Insurance Verifications and Benefits
Once your practice becomes a participating provider with these insurances you can start accepting patients with those insurances. One of the perks of being PAR with these payors is that you can have access to online portals that are available. These portals are extremely convenient and give you access to a multitude of resources - benefit information being one of them.
Many of these insurances can be found on hub portals such as Availity, but other insurances have their own portals such as state Medicaid programs and Medicare. Setting up these portals is generally a simple process where you have to register your NPIs and TINs for each location, create a user login and password, then verify your information.
One of the resources on these portals lets you check benefit information for policyholders. This will help your practice as well as the patient have a better understanding of patient responsibility and cost-share amounts for the services you are providing. The most important items to confirm while checking benefits are:
Authorization requirements (be sure to confirm if this is handled by a third party vendor rather than the insurance)
Copays
Coinsurance
Deductible
Out of pocket expenses
Visit limits (this is not the same as authorized visits)
After you have verified the benefits and confirmed accumulations for each cost-share item, provide this information to the patient prior to him/her starting treatment. This is best done by completing a financial responsibility sheet or insurance benefits information sheet to include in the patient’s intake paperwork. The patient should attest to the benefits information and acknowledge that he/she is aware of the potential patient responsibility throughout the course of treatment.
This ensures there are no surprises to the patient or to your practice once the claims process. If the patient has a copay, you will be aware of that and can collect the copayment at each visit, rather than waiting to collect it once the claims process and your chances of collecting are significantly reduced once the patient leaves your clinic.
Bus Stop #3: Authorizations
Some insurance plans require authorization - and depending on the insurance this may be referred to as clinical submissions, precert, medical necessity review, etc. - so it’s important to understand each payor and the terminology they use when requiring an authorization. If this information is not on the portals then someone must call the insurance to confirm the authorization requirements. During a time where technology has consumed almost every aspect of society, a good old fashioned phone call to speak to a representative about the authorization is always worth making.
Online Portals / Requesting Authorizations
This information should be collected during the benefits check back at Bus Stop #2. The process for obtaining authorization should also be obtained during the benefits check. This is also a feature on some online portals where the benefits information is located, however, if the authorization is handled by a third party vendor, then you need to contact that vendor to have your processes in place for submitting these authorizations. These third party vendors often also have online portals to submit and check the status of authorizations.
Tracking System
There needs to be a diligent system in place to track and monitor your patients who require authorization. If the authorization is required before the eval, then your team needs to ensure the necessary steps are being taken to get the auth requested prior to eval date. There are several nuisances about authorizations that are imperative that you are aware of and you should always confirm which CPT codes require authorization.
Tracking and submitting authorizations will avoid losing reimbursement for services rendered due to missing authorizations. Your entire team should be involved in this process so they understand the “why” behind the importance of diligent tracking and requesting authorizations when they are needed. Once the authorization is approved and can be tracked in your billing software your team should be able to run reports and view patient charts to see when the authorization expires/the patient needs more visits.
Retroactive Authorizations
If an authorization is missed the next option is to attempt a retroactive request for authorization. Many insurances do not allow retroactive authorizations, but again, this information should be obtained during the initial benefits verification. If the retroactive authorization is denied, the final resort is appealing for medical necessity.
Bus Stop #4: Submitting Claims
This stop is one of the most satisfying stops along the Pathway to Payment. It combines all of your efforts from the previous stops and sends them off to the insurance for processing. This stop is also the intermission stop where we wait for the connecting bus to take us to the next stop.
Many payors have transitioned to electronic submissions of claims. Every billing software should have the option to physically print these claim forms and mail to the insurances as well as an option to set up EDI for electronic submissions for quicker turnaround times for claims processing.
The two key focuses at this stop are 1) ensure each payor is set up correctly and 2) be aware of timely filing deadlines.
When the payor settings are incorrect or do not coincide with the information the payor has on file for your location is when you run into denial issues which ultimately put you at a race against the clock to have claims resubmitted. Getting claims out the door is at its core the purpose of the revenue cycle, but getting claims out the door correctly the first time is what the focus should be on.
Common issues with claim submissions include submitting claims to the wrong physical address, having the wrong EDI set up for electronic claims, missing information on the claim forms, and missing timely filing deadlines. All of this information is easily attainable and should receive a high level of attention from the beginning. Once these payors are set up in the billing software you will likely not have to edit them again.
Take time to refine your process and ensure everything in your billing software is set up correctly before mass submitting claims. Once the claims are out the door - we wait.
Bus Stop #5: Accounts Receivable
At this point, we are about 30-45 days out from the first time a patient entered your practice for services. This stop is also very satisfying because you see the hard work from Stops #1-5 pay off - literally.
Overall, you should have a processed mapped out and strategy in place on how you will handle these sets of aged claims. The AR Team needs to be aware of nuisances across insurances as well as timely filing deadlines.
These items should be tracked and handled in an efficient and timely manner.
0-30 Days Aged
Aging reports for claims should be run in a timely manner starting with claims that are 0-30 days aged. Many of these claims will still be processing but it is important to keep track of them because 30 days quickly turns into 90 days if you are not conscientious of the aging process and running the aging reports.
30-60 Days Aged
Claims that have aged 30-60 days should be a primary focus since this is where you will catch any denials or rejections from either the clearinghouse (if claims were submitted electronically) or the insurance company for invalid/incorrect/missing information on the claim forms. This is a crucial bump in the road that can be remedied and the potential to collect on these claims is highly likely since this is usually still within most insurances’ timely filing limits.
60-90 Days Aged
This aging bucket is where you should be concerned with the reason for these claims aging out this far. Did the insurance pay and now you are waiting for the patient to pay? Did you miss a denial? What next steps need to be taken to resolve these claims?
90-120 Days Aged
This group of aged claims should sound the alarm for your AR Team. These claims either fell through the cracks of the previous aging buckets or you are waiting for payments from patients. At this point, all hands should be on deck to get claims reprocessed at the insurances - if timely filing limits allow this - or patients need to be called about their outstanding balances.
120+ Days Aged
Any claims outstanding at insurances at this stage should be addressed immediately to resolve the issues. If there is no other remedy for the claim, it will likely result in a write off.
Any patient balances that have aged this far should also be addressed immediately by making final calls to collect on the outstanding balances before they are sent to collections.
Bus Stop #6: Denials and Appeals
The final stop on the Pathway to Payment is addressing any denials that are discovered in the AR process at Stop #5. Common denials include missing authorizations, invalid member ID, missing provider information, and missing clinical documentation. Each of these can be easily avoided at their respective stops along the Pathway, which is why it is important to take your time at each stop to ensure everything is handled correctly before going to the next stop.
If the claims are returned for denials, some of the issues can be resolved by resubmitting the claims with corrected information and/or documentation.
Other claims may require additional work such as filing an appeal if they are denied for medical necessity or missing authorization. The appeals process for each insurance is different in that some require forms to be completed while others allow for a more informal request for appeal.
Either way, all insurances have timely filing deadlines for these appeals and they should be strictly abided by. This is your last chance to get paid on claims.
Paul Martin's Interview with Bryanne Johnson
Our CEO and Founder, Bryanne Johnson discusses the reimbursement challenges and opportunities as we move forward into 2021. Link provided below:
Things You Should Know, February 2021 Edition
Recently CMS published CCI edits that are effective retroactively to January 1, 2021. These edits significantly reduce the use of the 59, X, XE, XP, XS, and XU modifiers.
Historically, these modifiers have placed a significant burden on practices both clinically and administratively. These are the denials, adjustments, addendums and appeals that are worked day in and day out by our clinical and billing teams to obtain reimbursement for services furnished separately and distinctly.
We are excited to spread the news that Cigna, Aetna and now Humana have followed the course of CMS and have also eliminated the use of the modifiers in coding pairs that will be significant to our industry.
Each insurance company is taking a different route in processing the claims retroactively to January 1, 2021. Read more from the APTA here.
Have questions about your billing or coding? Questions about how to retroactively bill these claims? Let us know- we're here to help!
Happy Birthday, Mr. Lincoln!
As Abraham Lincoln once said, "give me 6 hours to chop down a tree and I'll spend the first four sharpening the axe."
At LRS, we pride ourselves on efficiency and process improvement. Our company is named after Abraham Lincoln - we focus on ways to make your practice more efficient and in turn, collect every penny of what you are owed.
As we venture into 2021, we have found the three points below as being a solid foundation for billing, coding and reimbursement. Struggling in one of these areas? Let's chat!
Coding Best Practices
Moving from basic to advanced activities - purpose, progression and compliance.
CMS v. AMA 8-Minute Rule
How each work and what they mean for you, your billing and your reimbursement.
59 Modifier Denials and Adjustments
Payers we see this with, adjustments v. denials, and how to approach these.
Stop Jumping Through Hoops in 2021!
Do you find yourself constantly jumping through hoops when it comes to credentialing?
Insurance companies have many hurdles in place to delay payment and oftentimes, credentialing providers can be one of the most exhausting - especially when you don’t want to focus on paperwork but instead on patient care and the customer service experience within your practice!
Here are some common hoops we see in credentialing and ways they can be combated:
Insurance panels closed:
It can take up to six months to hear back from an insurance panel once you have submitted an application! And after all that waiting, the insurance companies can come back saying that they are not open to taking new providers. This is incredibly frustrating but the best thing you can do in this time is be persistent. Continue to apply every 3-6 months. Follow-up with statistics and outcome measures as to why your practice should be selected to enter into the plan.
Extended wait times for processing especially due to COVID-19:
While waiting is the name of the game when it comes to credentialing, since COVID-19, we have seen even longer processing times due to the transition to remote workplace and the payors focus on putting in place waivers for Covid-19 emergency. We recommend continuing to submit credentialing in a timely manner but anticipate prolonged approvals times and plan for co-signs in the interim. Again - this is where persistence is key! Continue to follow-up regularly with the payors to ensure your applications are processing.
Lack of communication with your billing team causing denials:
Your billing and credentialing departments should have a solid process in place for communicating credentialing status’ and how that directly affects the submission of claims. It’s essential that your credentialing department shares all crucial information, including: pending, approved, and terminated credentialing status’; claims that need to be held and when those claims are okay to be submitted; and contract intricacies to ensure that the EMR and claims reflect the contract details. If not, you will see denials that are often not appealable.
We know that credentialing and re-credentialing and the hoops they have can cause you and your practice headaches and cause delays for cash flow. If you are interested in having LRS handle your credentialing, contact us to learn more!
Busting a Move into 2021
Busting a Move into 2021
We have been through so many things this year. COVID-19 uprooting our ways of living and working. NCCI edit reversals and what has felt like endless denials because of these changes. And to cap it off - the CMS Final Rule solidifying Medicare payment cuts.
But now we are less than 2 weeks away from 2021. It is time to focus on the future and what you can control. You can finally put back on your dancing shoes and get your practice ready to move and groove again in the New Year!
Here are a few things you should be doing to ensure you will be rocking into 2021:
1) Analyze your collections and your AR.
Do you know what your revenue per visit is? How has it trended in 2020? How has your payor mix shifted through COVID-19? How much of your AR is outstanding at 90+ days? We know the Medicare payment cuts are coming but that is exactly why you should be ensuring your AR is as clean as possible. Collect on every penny you are owed. It is your best safeguard against the payment cuts.
2) Appeal. Appeal. Appeal.
While it seems the NCCI edits may be reversed, AGAIN, in the coming year - you have likely taken a huge hit since they were reinstated in October. Have you analyzed your revenue per code for popular NCCI edit users like Humana and BCBS? Take a look at common bundling denial codes such as 97530 and 97140. Have those been adjusted off or are they in the appeals process? Just like collecting on your AR, appealing these codes are an essential way to make up the difference for the looming payment cuts.
3) Clean up your administrative processes.
Did you receive credentialing denials in 2020? These are completely avoidable. What is your referral conversion rate? How many denials did you receive for no authorization this year? Due to the upcoming payment cuts and continued COVID-19 surges, you cannot afford to be receiving denials for these preventable issues and you also need to be focused on getting as many patients on the schedule as possible in the New Year.
Are you worried about your answers to these questions and that you may be late to the 2021 dance party because of it? LRS can help! We can do a free strategic analysis and reconciliation to see where you may be missing out on cash in the bank. Contact us today to learn more!
Boots On The Groud Webinar
Join the LRS' leadership team for an interactive webinar on Wednesday, December 2nd at 12:00pm EST that will highlight trends in denials, authorization for services, credentialing and contracting, and other billing issues that you should be aware of as you prepare your strategic plan for 2021.
Thing You Should Know This Week 11.19.2020
2021 Medicare Deductibles and Premiums Announced
CMS announced the 2021 Medicare Part A and Part B Deductibles and Premiums:
The standard monthly premium for Medicare Part B enrollees will be $148.50 for 2021, an increase of $3.90 from $144.60 in 2020.
The annual deductible for all Medicare Part B beneficiaries is $203 in 2021, an increase of $5 from the annual deductible of $198 in 2020.
The Medicare Part A inpatient hospital deductible that beneficiaries will pay when admitted to the hospital will be $1,484 in 2021, an increase of $76 from $1,408 in 2020. The Part A inpatient hospital deductible covers beneficiaries’ share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period.
99072 Use
As we shared before, the AMA released the new CPT code 99072 to be used for "Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease."
Additional means above and beyond what you would normally perform on a typical visit.
Tricare and Low Back Diagnosis Coverage
TRICARE is now offering a program that waives cost-sharing for up to three physical therapy visits for people with low back pain. This program will be available between Jan. 1, 2021, through Dec. 31, 2023, for those that have TRICARE insurance and live in one of these 10 states: Arizona, California, Colorado, Florida, Georgia, Kentucky, North Carolina, Ohio, Tennessee, and Virginia. Learn more about the requirements at ChoosePT by the APTA.
Save the Date: Next LRS Webinar
Join us on December 2nd at 12pm ET for our next webinar: LRS' Boots on the Ground - What We Are Seeing Heading Into 2021. The LRS leadership team will highlight trends in denials, authorization for services, credentialing and contracting, and other billing issues you should be aware of as you prepare your budgets and plan for 2021.