Evaluation & Management: the History Component

MedPro Services strives to maintain current knowledge of the ever-changing medical billing and coding industry.  In one of our many continuing education efforts, a group from the MedPro Services’ team recently attended the Karen Zupko & Associates conference on General Surgery coding in Chicago, IL.  With the recent changes in the healthcare industry, medical billers/coders and providers alike must be especially vigilant in maintaining appropriate and accurate practices.  Insurance companies are cracking down on coding and billing errors and ensuring that provider reimbursement reflects services rendered.  With insurance auditing on the rise, providers must make sure that documentation and coding meets the Centers for Medicare and Medicaid Services (CMS) guidelines.  Over the next few weeks, I will be writing a series of posts highlighting some of the most integral aspects of what we learned at the conference and what we feel providers should know to keep their practices operating as efficiently and successfully as possible.

Today’s post focuses on something almost everyone in the medical billing industry is highly aware of, are continuously learning about, and is one of the most commonly miscoded and over-billed services: the evaluation and management (E/M).  This was a hot topic at the conference and something that all medical billing companies should be acutely aware of and knowledgeable on.  From personal experience, I can tell you that E/M codes are notoriously difficult to code simply because the CMS language is not as clear as it is for other areas of coding.  The most important thing to consider when coding E/M services is documentation.  Regardless of what happened in the exam room, documentation MUST meet CMS guidelines to bill varying levels of services.  Without appropriate and accurate documentation to support the level of service billed, providers are really opening themselves up for major issues with payors and very possibly the law.  As was mentioned in a previous post, today’s electronic health records (EHR) systems are highly intuitive and useful in hitting all of the necessary documentation markers.  Do NOT fall pray to templates and cloning.  Always document the unique aspects of each examination.

The speakers at the conference spoke extensively on correct E/M coding.  To code E/M’s properly, providers must be aware of three main components: history, exam, and medical decision making.  The level at which each of these are completed is what determines the level of service billed.  I must emphasize that wordy or over-documentation does NOT equate a higher level of E/M.  Because each component requires a great deal of consideration, I am only focusing on the history component in this post.

What does the history component in an E/M entail?  There are some important areas that should be hit to ensure that a history component is accurately and appropriately performed and documented. First, what is the chief complaint?  Document this in a clear and efficient statement, basically explaining why the patient is presenting for the visit.  Second, the history of present illness (HPI) should be performed and documented.  An HPI includes such things as when and where the injury or illness began to occur/appear, symptoms of the illness, when the injury/illness seems to worsen or get better, how often is it experienced and in what environments, etc.  Detail clearly the history behind the patient’s condition.  Third, past, family, social history (PFSH) should be addressed.  PFSH is pretty self explanatory, but includes such details as any family diseases, social history, such as smoking and alcohol use, etc.  Finally, a review of systems (ROS) is needed in the history component of the visit.  An ROS is as it sounds, a review of different bodily systems and part, such as the eyes, the heart, respiration, etc.  PFSH and ROS may be documented on a patient-completed form, but the provider must review this with the patient to ensure accuracy and to ask any questions that may arise.

Clearly coding E/M services is lengthy and requires special attention to detail, but doing so will result in not only more accurate and appropriate payor reimbursement, but will also help to maintain practice integrity and better patient care.  MedPro Services is continually educating and informing our providers on appropriate and accurate E/M documenting and coding.  We strive to ensure that documentation meets CMS standards and is reflective of actual services rendered.  In the following weeks, I hope to address further aspects of E/M coding and how MedPro Services can help providers address any areas of issue or concern with the topic.  If you have questions on E/M coding or are concerned your current billing company is not performing up-to-par, feel free to send us a message detailing your questions and concerns.

EHRs are the Solution: Making a Successful Transition

Considering some of the pitfalls and drawbacks of using an electronic health record (EHR) system as were mentioned in my previous post, one might be reluctant to use EHRs to their full potential.  However, most EHRs today are highly intuitive and have features that are more likely to benefit a practice than damage it. The MedPro team has worked with numerous providers on the transition from a paper-based health records system to an electronic one and the experience has varied from provider-to-provider.  Hayes (2017) also offers some suggestions on making the transition as smooth as possible and ensuring the success of providers with their chosen EHR:

  • Maintain open-communication with the provider. As a medical biller, it is critical to be open with the provider and allow them to discuss any misgivings they may have with the transition.  Offer practical solutions to any of their questions and concerns and present any you may have yourself.  Most often, providers are not experts in coding, which is why we as medical billers must be aware of areas for potential improvement and provider suggestions for things such as better documentation and coding.
  • Identify areas in which problems have occurred in the past when a paper-based system was used. I can attest that providers are not always aware of the type of documentation needed to ensure proper coding and billing.  Accurate and necessary documentation is a skill that sometimes needs guidance and as professional medical billers, this is something that we can provide support on.
  • The provider is not the only individual in the office maintaining and using the EHR. Ensure that all office staff and billing staff are aware of the functions of the system and provide roles for each person who will be using it.  Training is absolutely essential for everyone who will be using the EHR.  Providers, especially, should be trained on how to appropriately use templates, which can be highly efficient and time saving when used appropriately, to avoid the drawbacks of “cloning”.   Providers should be focusing on patient care and any help they get with documentation can be essential for ensuring that patient care remains their top priority.
  • One of the goals of most EHRs is to allow for proper documentation and reporting of all upcoming CMS initiatives. As a medical billing company, we try to discuss with providers and staff on how EHRs can be used to meet these goals, how this feature will be maintained, and areas that may need improvement to ensure all initiative markers are met.

Each practice and provider differs in terms of what they are seeking from their chosen EHR and what the demands of that practice/provider require.   In my experience, some providers find transitioning to be a daunting task and are at first reluctant to change.  However, it is partially the responsibility of the medical billing team to help with this transition and to offer counseling and solutions along the way.  In today’s healthcare, electronically-based records systems are really the best way for any practice to store patient medical information and should never be avoided.  In my personal experience, I have worked with providers who were at first adverse to change, but once we provided the necessary consultation and information, we were able to put their concerns at ease and transition them smoothly to a new and more compliant system.  EHRs provide for a much cleaner, efficient means for storing medical records.  The MedPro Services team is well-versed in various EHRs and is willing and capable of learning and adapting to new ones too.  For more information on our experience with EHRs, please visit the PM and EHR Solutions section of our website.

Hayes, J. (2017, September). EHR transition is an open opportunity to improve documentation. Healthcare Business Monthly, 48-49.

Are You Avoiding EHR Perils?

Electronic Health Record (EHR) systems are an integral part of today’s healthcare.  Not only do they provide quicker, easier, and more accessible means for storing patient health information, most EHRs offer critical features that help providers to properly document and report meaningful use.  Per Clements (2017), EHRs can be beneficial in a variety of ways, such as:

  • Allowing for more efficient, complete, and legible documentation
  • Providing easier and immediate access to medical records and patient information
  • Coordinating care among providers

EHRs are designed to assist and help providers by offering a more technologically advanced means for storing and accessing patient health information. Even with the numerous benefits that EHRs provide, they are not without potential pitfalls and limitations.  Clements (2017) points out areas in which EHR features may be used inappropriately or inadequately:

  • Many EHRs offer a “cloning” or copy and paste feature, which allows physicians to transfer information from prior visits that may be relevant for a current visit in a fast and efficient way.  However, auto-populating or copy and paste/cloning features can potentially lead to fraudulent or inaccurate documentation.  Documentation may be carried over that is no longer relevant to the patient or is not relevant to the current visit.
  • Building off the cloning point, over-documentation can also be a problem.  Copying and pasting, auto-population, or simply over-documentation to justify the billing of a higher evaluation and management (E/M) code is fraudulent and unethical.  Each visit should be documented based on what occurred during that particular visit.  It is best to not use the auto-population templates or cloning features to avoid these issues entirely.   I cannot stress enough that over-documentation does not equate medical necessity for billing higher-level E/M codes. E/M codes should meet all of the specified CMS guidelines for medical necessity.
  • Some EHRs offer the provider the ability to generate diagnosis and procedure codes based on descriptors in the documentation.  While this is clearly an efficient means for documenting patient conditions and procedures performed during a given visit, it is NOT to be solely relied upon.  Providers or other clinical employees should ensure that all diagnoses and procedures are coded and generated appropriately.  With the onset of ICD-10, diagnosis codes should be monitored for the highest accuracy and specificity possible and unspecified codes, which from my experience are the most commonly auto-generated in EHRs, should be avoided.

More and more often in the medical billing industry we are seeing insurance companies control for appropriate and accurate billing (e.g. medical records requests, CMS initiatives) through companies such as Optum.  Insurance companies are only ensuring that providers are maintaining authentic patient medical information and are billing only what is accurate and necessary. Poor or inappropriate documentation due to the above mentioned EHR issues can lead to insurance denials and fraudulent billing, both of which providers and medical billers certainly want to avoid.  At MedPro Services, we strive to find EHRs that fit our providers’ needs and consult on ways in which the EHR can be used more effectively and appropriately where applicable.  We are familiar with numerous EHRs and are always willing to provide recommendations.  Please contact us for more information.

Clements, A. (2017, October). Conquer E/M challenges of EHRs. Healthcare Business Monthly, 46-49.

 

Are Payor Non-payment Issues Affecting your Practice?

It is our responsibility as a third-party, medical billing company to monitor all insurance payment trends and activity to ensure that our clients are receiving the highest and most accurate reimbursement possible.  Often we see insurance payors from all over the nation across all of our clients using incorrect denial codes or applying improper fee schedules.  As a medical billing company, we must be vigilant in identifying issues of integrity with insurance payors.  Some of the most common issues we see involve:

  • Global denials/issues.  These types of denials are marked by multiple non-payments, low-payments, or incorrectly applied denial codes.  Your billing company should be prepared to monitor denial reasoning codes, know what they mean, and recognize when an error has occurred.  Global denials/issues tend to happen across almost all patient claims from a particular insurance company and are fairly easy to identify.  If these types of denials occur, then your medical billing company should immediately contact the insurance payor, preferably the appointed provider representative, and work to correct the error right away.
  • Improperly applied denials.  Insurance payors are incredibly notorious for issuing unfounded claims denials (e.g. no authorization when one was not needed, CPT bundling).  Your billing team must be aware when a denial code is incorrectly applied and how to fix these denials at the onset.  It is possible that insurance payors experience system glitches, which could lead to these types of denials, or it could be a way for insurance payors to avoid making appropriate payment on a claim line.  As a medical billing company, it is almost impossible for us to truly know the reasoning behind improperly applied denials.  Regardless, we must identify when errors like this occur and rectify the issues in a timely fashion as not to disrupt the revenue stream.
  • Fee schedule errors.  I am continually astonished to find that legally-binding contracts are breached on a regular basis on the part of the insurance payor.  More and more we are seeing fee schedules improperly applied, thus leading to lower than required reimbursement.  Your medical billing company should absolutely be monitoring each insurance payor’s fee schedules per your agreed upon contract.  While these are not difficult to apply by hand with the appropriate tools and technology, most practice management (PM) systems have the capability of applying fee schedules at the time of payment posting, allowing for quick identification of incorrect payment.  Our PM system, Healthpac, is readily equipped with this feature and we continuously monitor fee schedule errors and have been very successful in correcting issues with the insurance payor almost as soon as errors are identified.
  • Payor specific “rules.”  As remarkable as it may seem, not all insurance companies are bound by law to follow a specific set of guidelines for billing and reimbursement.  While more and more companies are adopting CMS-guidelines, some actually have payor-specific guidelines, which really are not easily identifiable until a denial or reduction in payment occurs.  Your medical billing team should have the knowledge of how to access payor specific “guidelines” and should contact the payor with further questions should these types of denials and issues arise.

As a medical billing company, we continuously identify payor issues when we are posting payments.  MedPro Services staff are highly skilled in quick claims follow-up and correcting any payor non-payment issues almost immediately upon receiving them.  At some point in time, we have run into each of the above mentioned non-payment issues and have found the best means for addressing each of these issues, so that our providers experience minimal delay in receiving the correct reimbursement.  Are you questioning your medical billing team’s skill in rectifying and monitoring non-payment issues?  Please feel free to contact us for more information on how we can improve your practice’s revenue stream.

Taking Full Advantage of Electronic Payor Systems

Electronic payor systems are growing in popularity as the medical billing industry adapts to an increasingly paperless world.  Today’s major payors, such as UnitedHealthcare and Aetna, offer completely electronic solutions for submitting and managing claims, reimbursement, and provider/administrative solutions.  Some of the most well-known of these online systems are OptumNavinetAvaility, and many more.

There are numerous benefits to taking advantage of these systems.  These include, but certainly aren’t limited to:

  • Claim Status:  A number of these electronic solutions, such as Optum and Navinet, allow for identifying claim status (e.g. pending, adjudicated, paid, or denied).  This cuts down on calling time and allows for instant verification of claims receipt and where the claim stands with the payor.  This feature significantly cuts down on time wasted waiting to speak with insurance representatives and provides more substantial evidence of claims receipt and status.
  • Appeals & Claims Corrections:  Gone are the days of paper appeals and claims corrections.  Numerous payors allow for online appeal submission and claims corrections.  Submitting appeals and claims corrections electronically/online allows for better tracking of these submissions and faster processing time.  As a medical billing company, we utilize these functions on a daily basis.  Online access to appeals and claims corrections allows us to see in real-time what the status of these submissions are and if further work is needed.  It also decreases the amount of time spent calling insurance companies and waiting to speak to a representative, who may or may not have the information we need.  It also decreases the potential for “lost mail” or appeals that have been received, but are never even reviewed.
  • Electronic Remittance Advice (ERA):  In today’s world, we no longer have to wait for payments and explanation of benefits to be mailed.  Not only can we receive remittance advice through our online clearinghouse, but we can also obtain the original ERA from the payor’s electronic system.  This is especially useful for finding payments from payors, who may not submit ERAs through your chosen clearinghouse.  Even if ERAs are received through an online clearinghouse, the exact remit information may differ from what the actual payor ERA states.  It is important for medical billers to know where and how to access the original payor remits for purposes of follow-up and appeals.
  • Authorizations: Authorizations can be easily obtained and retrieved from numerous electronic payor systems.  Some systems even allow authorization verification for certain procedure codes.  Various insurance companies require that authorizations be obtained online.  This feature is especially useful for office staff and those responsible for obtaining authorizations.
  • Administrative Functions:  A number of these electronic systems will allow for a certain amount of administrative functions to occur online.  Some offer the ability to update provider information, which must be updated on a regular basis to avoid any delays in processing and payments for a particular provider.  It also allows for important letters and messages to be received that may otherwise take longer when received through mail.  Payor-provider communication is also possible on a number of these systems.  Utilizing this feature allows for more accurate record of communications, less time on the telephone, and quicker turn-around time.

Because most of these services are readily available and relatively easy to use, there really is no excuse for a medical billing team to not use them.  However, we still continue to encounter office staff, providers, and medical billing teams that do not utilize these systems to their fullest potential or at all.  This is true for large practices and small practices alike.  Avoidance of electronic payor systems not only wastes valuable time and resources (e.g. reimbursement), but it also increases the risk for not addressing follow-up in a timely fashion.

At MedPro Services, our staff is highly-aware of numerous electronic payor systems and will use them to the highest potential possible.  We have had incredible success with addressing appeals, finding claim status, correcting claims information, retrieving authorizations, communicating with payors, and updating provider information while utilizing these systems.  You can find out more about our relationship with a number of electronic payor systems here.

Is Your Data Entry Team Working for You?

The very first step in successful medical billing is having a reliable, educated data entry team.  Data entry is the first point at which the claims process begins for medical practices and is, arguably, one of the most important aspects of medical billing.  A medical billing team must have proven accuracy and extensive knowledge of the data entry process because without these things the practice runs of the risk of lost revenue and the potential for failure.

A poorly motivated, under or improperly educated, and inadequately trained data entry team is destined to make costly errors, resulting in huge initial revenue losses for the practice.  While most of these errors can be fixed during follow-up, it is best to avoid data entry errors in the first place because additional work does equal additional costs.  From my experience in medical billing, there are two main types of data entry errors:

  • Demographic errors.  Incorrectly entered data, such as names, insurance numbers, and dates of birth, can result in insurance denials, which can delay payment and result in additional work and resources.  To avoid such errors, have patient demographics prepared electronically, as handwriting is often difficult to read.  Require that the data entry team check all demographic information at least once before charges are entered.  Provide clear copies of patient identification and insurance cards (both the front and the back).  Having an intuitive clearinghouse, such as the Zirmed, may help to stop any of these errors from even reaching payors.
  • Coding errors.  Far too often, data entry errors occur at the time of charge entry.  This is most likely the result of having poorly trained and inadequately educated data entry clerks.  I want to emphasize that medical billing and coding certification does NOT equate expertise in medical billing.  Just because an employee has the credentials does not mean that he or she is a skilled medical billing expert.  Data entry in medical billing is not an easy trade and is a position that requires a strong skill set in the task at hand.  Because of the complicated nature of medical billing, charge entry goes beyond entering whatever information is presented on the superbill.  Providers make mistakes and even though most providers have extensive knowledge in medical billing, superbill errors still occur.  Ultimately, it is the responsibility of the medical billing team to ensure that all claims are being billed correctly and that charges are not simply copied from the superbill.  This skill takes training, education, and thought.  Some common coding errors are: missed or incorrectly used modifiers, inappropriate procedure codes, incorrectly coded diagnoses, place of service errors, and bundling errors.  Data entry clerks must be knowledgeable on claims coding guidelines.  This also includes billing appropriately, even when reimbursement will not be likely.  Coding charges incorrectly just to obtain reimbursement is illegal and could result in auditing.  As a general rule of thumb, provide the medical billing team with the medical reports, so that greater specificity and accuracy can be made when billing out charges.

MedPro Services’ data entry team is comprised of knowledgeable, highly educated staff with extensive expertise in the field.  We take the time to properly train our team on claims coding guidelines and ensure that all checks and balances are in place prior to claims submission.  As a team, we strive for continued education and obtaining current knowledge of claims coding guidelines.  Our staff is highly motivated in obtaining top revenue for our clients because if our providers are losing money, then so are we.  For more information on our data entry services, please visit the data entry section of our website.

MedPro Services also offers consulting.  Our consultation services can help you determine if you are getting the best possible outcomes from your current medical billing department or company and can offer insights into potential areas of improvement, particularly in areas of data entry.  For more information on our consulting services, please visit our dedicated Consultation page.

Appeals Best Practices

Providers and medical billers are well-aware that insurance companies will not always pay every claim for the agreed upon rate and for reasons that vary across the board.  When denials or underpayments do occur, it is best practice to first identify if the claims issue needs appealing.  Because appealing is a lengthy and sometimes difficult process, it should be used as one of the final options in basic claims follow-up.  Prior to appealing, the following should be considered:

  • Correct billing:  Commonly, claims denials are the result of data entry errors.  Humans make mistakes and in an industry that relies on minimal human error to be successful, denials based on human error are, unfortunately, not uncommon.  Before appealing a claims denial, determine if the claim was billed cleanly and correctly the first time.  Common data entry denials might include errors in patient insurance information, bundling denials resulting from incorrect modifier usage, or missing information (e.g. referring doctor, accident/injury date, quantity).  Some questions to consider would be: Were the appropriate modifiers used?; Is there a mismatch between the CPT and diagnosis used?; Is any basic patient information missing on the claim?
  • CPT guidelines:  Following CPT guidelines is not always easy to accomplish.  Currently, insurance companies are not required to follow nationally recognized guidelines, such as CMS guidelines, making claims denials all the more difficult to bill cleanly initially and sometimes to appeal.  Even if correct CMS guidelines are followed when initially billing, sometimes insurance companies do not follow these guidelines.  If you are certain that a claim was billed correctly initially, then check the insurance payor’s provider billing or administrative guide.  These guides are usually available online.  If they are not, promptly request one from the carrier.
  • Payor/Provider contract:  Contracting with an insurance company sometimes requires that certain services will be paid at a specific rate and/or may not be billable at all.  Determine that contracted services are being billed and are being billed appropriately.  If contractual procedures are not being followed, then an appeal may not be possible.  It is important for the provider and medical biller to be aware of contractual requirements as well as contracted payor fee schedules to determine that the payor, as well as the provider, are following the requirements set forth by the contract.

When it is determined that an appeal is necessary, then the appeal should be completed promptly and correctly.  The appeals process varies from carrier-to-carrier, so your medical billing company should be well-versed in the appeals processes of common insurance carriers, such as UnitedHealthcare, Aetna, BlueCross and BlueShield (may vary by state), and Medicare (exact process may vary based on the medicare handler).

Most insurance carriers have a standard appeal time frame.  For some, it could be as soon as 45 days after the denial is received.  For others, it could up to a year.  Still for some, there may not even be a timely appeals filing limit.  It truly varies based on the payor.

The exact appeals process may also vary based on the carrier.  As of 2017, numerous insurance carriers, such as UnitedHealthcare and some Medicare handlers, offer the ability to appeal and monitor appeals online.  If an online/electronic means for filing a appeals is available, then the provider or medical biller should absolutely use this method to file an appeal.  However, even in our modern era, some insurance companies still require appeals to be faxed or mailed, making appeal tracking much more difficult, costly, and timely.  If an appeal is filed via fax or mail, your medical biller should follow-up within seven days of filing to ensure that the appeal was received and what the status of the appeal is.  Always maintain a “paper trail,” collecting reference numbers for every call, appeal document tracking numbers, and documenting all conversations with representatives, ensuring that names and employee id’s are documented.  Most insurance companies will have a timeframe for when an appeal will be complete.  The medical biller should continuously follow-up to determine if an appeal is being processed within that given timeframe.  Finally, copies of appeals should be kept for future reference in a secure location, such as a secure server or on a secure, HIPAA compliant online document storage solution.

The above information on appeals best practices are put forth by MedPro Services.  Our team follows these procedures and more, ensuring that our providers are getting paid on time and for what they are owed.  For more information on our A/R recovery and appeals solutions, visit our site here.

Welcome to the New MedPro Website

Over the past few months, we have been working on crafting a new and improved site, which details the services we provide and who we are as a team.  At MedPro Services, we pride ourselves not only in the quality of service we provide, but also in the personal touch that we can provide our clients.  We think that the new website provides more insight into who we are and what we do.

The new site highlights numerous categories, some of which are the actual services which we provide.  The following are some of the most commonly requested services:

  • Data Entry:  We pride ourselves in the accuracy and quality of our data entry services.  Data entry usually begins with demographic entry, at which point we ensure that all patient demographic information is accurate and current.  Our skilled charge entry team is knowledgable in current CMS, AMA, and ACA billing guidelines and incorporates this knowledge when entering client charges.  Not only are we familiar with various EMR/EHR solutions, but our billing software also has the capability of interfacing with numerous EMR/EHR platforms.  We also post payments for our clients and are experienced in utilizing electronic payment solutions (e.g. Change Healthcare, PaySpan) and our state-of-the-art clearinghouse, Zirmed.  At MedPro Services, it is our belief that data entry is the first step in ensuring our clients are receiving the best possible outcomes and highest revenue possible.
  • Clean ClaimsOur team is comprised of highly-skilled claims representatives, who are aware of the multiple means for submitting claims, the filing preferences of various insurance carriers, and the limits for timely filing, an aspect of insurance claims filing that varies from carrier-to-carrier.  We use a multi-tiered process for scrubbing claims and ensuring that claims are submitted cleanly upon first submission.
  • A/R Recovery: Something that sets us apart from the competition is our focus on A/R recovery.  Each claim, no matter the dollar amount, is important to us and to our clients.  If A/R is neglected, then the client is missing out on high potentials for revenue.  Some of our competitors strive for “easy money,” which is the revenue obtained by simply submitting claims and not following-up on those that did not pay.  This method results in high-profit margins for the billing service, but severely affects the client’s bottom line.  At MedPro, we follow up on all claims, all the time and have a proven record of increasing client revenue by as much as 30% within the first 3-6 months.
  • Credentialing & ConsultingBeyond the traditional medical billing services, we provide credentialing and consulting services as well.  Credentialing is one of the more difficult aspects of running a practice.  It is time consuming, requires detail and skill, and can be daunting for those unfamiliar with the process.  Our in-house credentialing expert is aware of the credentialing processes for numerous payors and is prepared to help clients credential as swiftly as possible to avoid any timely payment issues.  For those interested in reviewing their current billing company, how their practice is performing overall, or wanting specific reports (e.g. collection ratio, days in A/R, payor insurance mix), we also offer consulting services.
  • Online Payment PortalWe offer online payment solutions through our clearinghouse, Zirmed.  This payment portal has given some of our clients the ability to collect patient payments quickly and efficiently, while allowing our team to post payments as soon as they are received. This solution also allows patients to pay online during times at which our office is closed, something that both patients and clients love.

Our new site also highlights our current team.  We have included a “Meet the Staff” portion of this site because we believe it is important for our current and future clients to know who we are as people.  Sometimes it helps to put a name to a face and allows even more of a personal touch.  We encourage you to check out our “Meet the Staff” and get to know each of us a little better.

What You Need to Know About HIPAA Compliance

The Health Insurance Portability and Accountability Act of 1996, or HIPAA, was developed with the goal of protecting sensitive and identifiable personal health information (PHI).  HIPAA (1996) is comprised of the Privacy Rule, the Security Rule, and Breach Notification Rule.  Under the Privacy Rule, entities, such as healthcare providers and medical billing companies, that work with personal health information are required by law to protect PHI.  The Privacy Rule also sets limits on how this PHI may be used (HIPAA, 1996).  With the advent of technology and electronic means for storing PHI came the Security Rule, which mandates standards for securing electronic personal health information (ePHI).  If a breach should occur, the law currently mandates that it be reported to the Secretary of Health and Human Services (HHS).

While HIPAA is complicated and continuously updated with the changing times, it is absolutely crucial for healthcare providers and their employees to be knowledgeable of the law.  Some ways to ensure that HIPAA compliance is being maintained in your office are:

  • Notice posting: HIPAA requires that notices be easily accessible to patients and that these are posted in office, are provided at the time of arrival, and are available on the provider’s website (Miller, 2017). Ensure that all members of your front office staff provide all patients with copies of HIPAA notices upon arriving to the office.  Display a HIPAA notice in a location in the office that is easily accessible and legible for patients.
  • Staff training: Regardless if staff are just starting out or long-time employees, it is essential that all staff members are knowledgeable and current on HIPAA compliance rules and regulations. Regular training would be optimal for office staff.
  • Assess/analyze: Perform yearly assessments or audits to determine if HIPAA compliance is being maintained in your office and if all ePHI is being handled in the appropriate and legal manner (Miller, 2017).

Today’s healthcare is continuously becoming electronically based, with the need for paper medical records going to the wayside.  With the Security Rule, providers are required to ensure protection of vulnerable ePHI.  This not only extends to the provider office, but also to any entity that deals with ePHI, such as clearinghouses, medical billing companies, and health plans.  There exists numerous electronic health records (EHR) systems that allow for better HIPAA compliance.  Our team highly recommends finding a HIPAA compliant EHR that works for your personal needs as a provider.

As a provider, you also need to partner with a medical billing company that values the importance of HIPAA.  At MedPro Services, all documents we transmit, maintain, and create with our clients are stored on a secure, off-site storage server.  In our office, all of our staff are educated and knowledgeable on current HIPAA practices and continuously strive to maintain compliance in our office.  When possible, we inform our providers of potential security breaches and areas of possible improvement to better preserve HIPAA compliance.  Our practice management system, Healthpac, is…..

HIPAA violations are no joke and no small matter.  Violators may be fined up to $1.5 million and may face up to 10 years in prison (AMA). To avoid consequences such as these, it is important to work with your staff and ensure that you are working with a medical billing company that values security and compliance.

References:

American Medical Association (AMA) (n.d.) HIPAA violations & enforcement. American Medical Assocation. Retrieved from https://www.ama-assn.org/practice-management/hipaa-violations-enforcement

Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191

Miller, S. (2017, July). Troubleshoot HIPAA vulnerabilities with risk analysis and assessment. Healthcare Business Monthly, 44.

 

Importance of Patient Collections

Changes in the US healthcare system over the past decade have led to higher patient financial responsibility.  Per the Kaiser Family Foundation (2016), patient out-of-pocket expenses have increased substantially over the last decade, due to such things as high-deductible policies and greater cost-sharing expenses (e.g. co-pays, co-insurance).  As a billing company, it is our responsibility to inform our clients of the best possible means for collecting patient balances and to help maintain consistency in patient collections in our billing office and in the main office.

Cavanaugh (2017) provides some suggestions for increasing patient collections and maintaining up-to-date policies and education in the office.  I have considered these suggestions and added my own suggestions from personal experiences as well:

  • Staying Current on Payor Policies: It is critical for billing companies and office management to stay current on payor requirements for collecting patient balances. Most insurance companies put forth a set of requirements for collecting on patient deductibles, co-pays, and co-insurances.  Efforts must be made on patient balances before they are discounted or completely written off.  Failure to follow these requirements could mean a breach of contract, which could lead to contract termination and restrictions of contract-renewal.  MedPro Services’ staff strives to remain current on payor policies and we continuously inform our clients of these policies.
  • Patient Responsibility Policies: It is crucial for a practice to have a set and firm patient responsibility policy in place.  A patient responsibility policy may include how and when the patient will be billed, as well as expected payment timeframes.  A copy of the policy should be provided to each patient or is should be discussed verbally, but most importantly, it should be provided in a way that is accessible and understandable to every patient.  Make sure every staff member, at the front office and in the billing office, knows the patient responsibility policy.  This must be maintained consistently and with fairness for every patient.
  • Collecting Up-Front: Most insurance companies require that co-payments are collected at the time of service.  Prior to providing services, the office staff must check that insurance cards are current and collect the co-pay amount that is often listed on the front of the card.  If this amount is not listed, verify patient eligibility and co-pay requirements.  Taking these steps will ensure that accurate co-pays are collected at the time-of-service.  Communicate with office staff the importance of collecting payment up-front.  At MedPro Services, we communicate daily with the main office staff on patient balances, co-pays, and any credits that may result from overpayment.  Doing so allows patient balances to be collected up-front and in the correct amount.  If patients request greater clarification, our staff is always willing to discuss balance questions with the patient.
  • Documentation: It is simply good practice to maintain quality documentation in a medical practice and billing office. Anytime a patient calls or comes into the office, document the conversation to some extent in the patient’s account.  Document and keep record of all patient payments.  At MedPro Services, our personal policy is to maintain and keep substantial records of any patient communications and payments.  If ever for any reason a patient payment is not posted or there is a complication with a particular account, then our documentation will provide explanation and clarification in these instances.  We work best with clients who maintain good documentation in the main office as well.
  • Multiple Means of Collection: By providing multiples means of collections, providers are giving patients more opportunities to pay balances in full and on-time. Consider accepting a wide-range of credit card carriers (e.g. Visa, MasterCard, American Express).  MedPro Services offers our clients Zirmed Patient Payments through our clearinghouse, Zirmed, which allows patients to pay online, check balances online, and aids the office staff in balance collection.  In our modern society, streamlined and intuitive solutions such as these simply make sense when collecting patient balances.
  • Quick Payment Posting and Statement Cycles: Our billing company strives to post patient payments quickly upon receipt.  This helps to clear out balances and eliminates aging patient debts and the potential for duplicate payment.  We send statements out weekly and ensure that patient addresses are current to help avoid returned statements, and thus, unpaid balances.

References:

Cavanaugh, M. (2017, May-June). Improve patient collections and stay compliant with payor requirements. The Journal of the Healthcare Business Management Association, 26-29.

Kaiser Family Foundation. (2016, September). 2016 Employer Health Benefits Survey. Retrieved from the Henry J. Kaiser Family Foundation website: http://www.kff.org/report-section/ehbs-2016-summary-of-findings/