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
1
Introductions
Ann Finn
518.522.8159 ann@ A NYS and NYC certified Women Owned Business (WBE)
2
2
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
3
3
March 2021 1
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
5
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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March 2021 2
MDHHS: Billing, Coding, and RCM in the Family Planning Setting
Front end
Key Questions and QI Activities
7
7
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
8
Ensuring Payers Set Up Properly Templates, codes and fees updated Ensuring System is Efficient
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8
Chat in: Challenges
? What is your biggest challenge with front desk / end activities?
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March 2021 3
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
12
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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March 2021 4
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
13
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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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March 2021 5
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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March 2021 6
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%
21
Gross Family Income 2021 # in family:
1 2 3 4 5 6 7 8 DISCOUNT
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