Billing, Coding, and Revenue Cycle Management in the ...

[Pages:46]MDHHS: Billing, Coding, and RCM in the Family Planning Setting

Billing, Coding, and Revenue Cycle Management in the Family Planning Setting

Presenter: Ann Finn Healthcare Reimbursement Consultant

AF Consulting, LLC March 25th and 26th, 2021

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Introductions

Ann Finn

518.522.8159 ann@ A NYS and NYC certified Women Owned Business (WBE)

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Agenda

Day 1

? Introductions ? Revenue Cycle Management ? Front End ? Clinical Encounter / Coding

Overview ? Questions

Day 2

? Telehealth ? Back End and Billing ? Scenario Reviews and

Discussion

? Closing

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MDHHS: Billing, Coding, and RCM in the Family Planning Setting

The Revenue Cycle

There are 3 main components of the revenue cycle, all of which offer opportunities to strengthen fiscal practices:

FRONT END

CLINICAL ENCOUNTER

BACK END

You Matter! Each person's role is essential to the team!

Front Desk

Clinical Staff

Check-out

Charge Capture and Billing Team

Management 4

4

Clinical Encounter

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5

Finding Opportunities

? Points where "breakdowns" occur ? "Work-a-rounds" that have developed ? Variations that occur ? Duplicate or unnecessary steps ? Review existing policies and procedures

vs. actual practices ? Unpaid services and denials ? root causes ? Working together as a team

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MDHHS: Billing, Coding, and RCM in the Family Planning Setting

Front end

Key Questions and QI Activities

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Front Desk Key Players & Activities

Call Center/Front Desk

Scheduling

Registration/Check-in

? Insurance verification, prior authorizations; Assess/enroll in Medicaid (MA)

? Accurate family size/income assessment

Consistent, Appropriate Messaging

IT ? Systems

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Ensuring Payers Set Up Properly Templates, codes and fees updated Ensuring System is Efficient

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Chat in: Challenges

? What is your biggest challenge with front desk / end activities?

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MDHHS: Billing, Coding, and RCM in the Family Planning Setting

Survey Responses: Front End Challenges

? Insurance verifications and eligibility ? Obtaining commercial insurance referrals/pre-auth (BCN) ? Scheduling / limited staff due to COVID ? No-shows, patients do not cancel ahead of time ? Getting inaccurate insurance information at front desk / input errors / Correct ID #'s ? Out of network plans and billing ? Too many rules with managed care plans ? Check out/providing patient bill with discounts ? Knowing what to bill up front for copays ? Denials due to front end

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Key Questions to Ask

? Number visits scheduled for each day? Policy/process for walk-ins /no shows? ? Registration policy/process? How is insurance information captured and verified? Done at

each visit? Prior authorization process? How is family size and income assessed? ? Patients screened for insurance coverage/eligibility? How can this be improved? ? What is % of patients in each fee discount category group on your sliding fee schedule?

How can this be improved? ? Front desk staff training done? Accurate messaging assessed? Scripts

offered? Documents needed for visit reviewed with patient? Missing information followed-up on? Input errors corrected? ? Adolescents' and patient confidentiality protection policy/process in regard to billing?

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Impact - Front Desk QI Example

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MH Medicaid FP visit

Per Visit Average

$100

PRE-QI

$ PER 6,000 Visits

POST QI

$ PER 6,000 Visits

25% $150,000 40%

$240,000

Private Insurance $75

20% $90,000

25%

$112,500

SelfPay/Uninsured

$5

45% $13,500

35%

$10,500

Unknown

$0

10%

$0

0%

$0

Total

100% $253,500 100% $363,000

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MDHHS: Billing, Coding, and RCM in the Family Planning Setting

Benefit Verification

? Clearly communicate information needed to verify insurance (at scheduling, reminder calls or texts, patient portal)

? Front desk staff should verify patient coverage before EACH visit ? Make copy of insurance card at visit ? EHR, clearinghouse, internet companies offer services

? Run batch night before ? Run at visit if needed

? LARC manufacturers also offer a free benefit verification process ? Create a tracking sheet by payer of benefits and needs for prior authorizations ? Set up contracts with plans you do business with - review

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MDHHS, Title X and Setting Fees

? Title X-funded health centers provide services regardless of one's ability to pay, insurance or lack thereof, and documentation status

? Use a Schedule of Discounts developed for individuals with family income between 101% and 250% of FPL to assure services are billed based on ability to pay (Section 8.4.2)

? Sub-recipients must use mandated quartile proportional increments MDHHS distributes each year in developing their Schedule of Discounts

? Can however request and receive an MDHHS approved waiver to use other proportional increments

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MDHHS, Title X and Setting Fees: Family Income

Patients < 100% FPL must NOT be charged

Bill all 3rd party payers

101% 250% FPL: charged discounted fees based

on Schedule of Discounts

Bill all 3rd party payers

Waive fees

for indiv > 100% FPL if Director determines

they are unable, for good cause,

to pay for FP services

> 250% FPL, charged per

Fee Schedule

Fees are set to recover

the reasonable

cost of providing services

Eligibility for discounts for

unemancipated minors who

receive confidential

services must be based on the income of the minor

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MDHHS: Billing, Coding, and RCM in the Family Planning Setting

SFDS: Best Practice

? Review the patient volumes in each of your sliding fee discount schedule categories

? Is there a distribution of discount amounts applied across self pay clients or are all your clients at 100% slide and no fees?

? Does it make sense to you or seem like an opportunity for improvement?

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Verification of Income

? Family income should be assessed before determining whether copayments or additional fees are charged.

? MDHHS does not require verification of income. Client income is self-reported.

? Income must be documented in the client record and there must be proof of application of the sliding fee scale.

? Eligibility for discounts for minors who receive confidential services must be based on the income of the minor (Section 8.4.5)

Your household size includes: ? Patient applying

? Spouse/Partner (w access to their income)

? Any children being supported in your household

? Anyone who is included on patient's federal income tax return

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2021 FPL

? Ava, a single mom with 2 young children, presents with no coverage

? How large is her household size? ? What is the maximum income she can

have to have her fees discounted to 0%?

PERSONS IN FAMILY/

HOUSEHOLD

FPL 2021

1

$12,880

2

$17,420

3

$21,960

4

$26,500

5

$31,040

6

$35,580

7

$40,120

8

$44,660

For family units with more than 8 persons, add $4,540 for each additional person. 18

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MDHHS: Billing, Coding, and RCM in the Family Planning Setting

Guidelines ? Copays / Deductibles

? Insured clients whose family income 250% FPL should NOT pay more (in copayments or additional fees) than what they would otherwise pay when the schedule of discounts is applied

(Section 8.4.6 )

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Applying Discounts

? Determine client's income, household size and whether she/he has insurance

? Check insurance eligibility and determine client's co-pay ? Determine where income puts client on sliding fee scale ? If co-pay < client would pay on sliding fee scale, pay co-pay, and

agency should bill insurance company fee for services. ? If the co-pay > what client would pay based on sliding fee scale, pay

based on the sliding fee scale, and the agency should bill the insurance company the fee for the services.

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? Ava's income is $28,000/year

? She has two children ? She has insurance. Her co-

pay is $20 ? To apply the sliding fee

scale, first, match her income to your sliding fee scale ? The sliding fee scale will show you the discount she would receive. In this situation, her discount would be 80%

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Gross Family Income 2021 # in family:

1 2 3 4 5 6 7 8 DISCOUNT

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