EHR Data Interface Issues for the Third Party Biller

 

Is the Industry Moving Away From Your Billing Model?

An article by Ron Sterling taken from the May/June issue of HBMA Billing.

Third party billers face a variety of business and technical challenges in interfacing with electronic health records (EHR) and other systems. Indeed, some of the initiatives in the healthcare industry will continue to complicate the establishment and maintenance of data interfaces for the foreseeable future.

Business Challenges

If you go back a few years before Meaningful Use, there were over 1,200 practice management system (PMS) vendors and a couple of hundred EHR vendors. During that time, the third party billers and/or practice management system vendors had the access to, and the attention of, physicians who needed to get their claims out of the door and paid. Consequently, it was the EHR vendors that would offer to accommodate interfaces with medical billing systems. Indeed, a variety of PMS vendors touted their systems as a gateway to a variety of EHR options for their physician clients.
Today, newly introduced integrated PMS/EHR products and EHR acquisitions by PMS vendors and vice versa have led to fewer, if any, billing system options for many EHR buyers. From integrated systems (that by design and business model do not interface with other products), to vendors that will not interface with other options, many vendors have established themselves as one stop shops for medical billing, EHR solutions, and, in some cases, RCM services. Indeed, some vendors have exclusive or "preferred" clearinghouse relationships for the handling of standard HIPAA transactions. In essence, more and more vendors want to position themselves as the only source for healthcare software solutions and services.

That is not to say that there are not EHR vendors who are eager to interface with a variety of practice management systems. However, the industry is moving to fewer interfaced solutions and more integrated offerings. Indeed, the majority of "new" solutions are integrated PMS/EHR offerings.

Healthcare Industry Changes

Related to the business challenges, the Meaningful Use initiative will affect interface strategies for all PMS and EHR products. For example, Stage 2 Meaningful Use core (required) measures include secure messaging with patients and providing electronic access to patient medical information. In most cases, this requires the use of a patient portal.

Patient portals can provide both medical billing and clinical interactions with patients. As importantly, most patient portals are designed to interface with one product line of medical billing and EHR products (such as Centricity PMS/EHR or NextGen EPM/EHR). Patient portals are not typically designed to interface with one vendor's practice management software containing billing data and a different vendor's EHR that houses clinical information. If the patient portal is separately interfaced with a PMS from one vendor and an EHR from a different vendor, the patient portal may not "know" how to properly route the message. In practice, however, patients may exchange secured messages with the practice on both billing and clinical issues.

A strategy that may include a separate patient portal for clinical issues and one for medical billing purposes presents a variety of operational challenges, including coordinating patient access and even accurately routing information. As importantly, separate patient portals will undermine support for the Patient Centered Medical Home and Accountable Care Organizations. For example, a patient who accesses the medical billing patient portal may not be reminded about a clinically-driven patient service issue.

Technical Challenges

Most interfaces are based on the Health Level 7 (HL7) structure. However, various aspects of HL7 are open to interpretation by vendors. Indeed, a variety of PMS and EHR vendors do not strictly support the HL7 standard. For example, some vendors use general HL7 messages instead of designated HL7 messages to send information. In other instances, the information in a message is not placed in the expected place but in a comment or supplemental area. Indeed, some vendors do not use the standard code sets, and instead use text fragments. In each case, the effort to establish the interface may require a painstaking evaluation of the vendor's "HL7" implementation.

Even after achieving success, the interface may have to change to address evolving coordination of information requirements between the medical billing and clinical record functions. For example:

• The Meaningful Use Stage 1 measures require ethnicity and race information that is commonly captured in the PM systems but is needed by the EHR to track provider performance and qualify for the EHR incentive payments from Medicare or Medicaid.
• Meaningful Use Stage 2 will require sharing of contact information and email addresses.
• The HIPAA omnibus rules will affect the information needed to track HIPAA Privacy and Disclosure as well as support exchanges with patients. As a practical matter, most medical billing and EHR interfaces do a poor job of coordinating HIPAA privacy and disclosure status for patients.

In light of these increasingly complex business and technical challenges to interfacing medical billing and EHR products, third party billers may need to establish their own preferred relationships with EHR vendors. However, such relationships will be under increasing competitive pressure and user demands to provide a more coordinated approach to patient service and provider relationships.

Right, wrong, or indifferent, the healthcare industry is moving towards comprehensive solutions to meet patient service challenges and optimize provider performance. Consequentially, the PMS/EHR vendors are addressing those needs. A myriad of changes that affect physician relationships with patients and the expectations of patients and payors will complicate the use of interfaces with EHR products and inhibit the efficiencies needed to manage patient care and service. As importantly, interfaced systems may complicate reporting for quality, operational, and management purposes.

Therefore, interfacing between PMS and EHR systems may present a tactical solution to meet physician needs in these relatively early stages of the transition to EHRs, but present a strategic challenge to address evolving healthcare business and patient service models. Third party billing organizations need to recognize these business and service issues in order to provide a clear strategic path for how your services and products will evolve to meet the new demands that your clients are facing.

Courtesy of: http://www.hbma.org/news/public-news/n_ehr-data-interface-issues-for-the-third-party-biller

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Three Mindsets for Growing Your Business and Sales

(An article by Ron Karr, taken from the July/August issue of HBMA Billing)

If I ask you not to think about pink elephants, what will you think about? Be honest! You're thinking about pink elephants! But why would you, when I asked you not to?

The answer is simple: the mind cannot process the negative. If you are about to go into an account hoping to not lose the sale, what do you think is going to happen? You will lose the sale. The opposite is thinking about the deal you are going to close. Thinking about what you want to achieve, instead of what you don't want to have happen, makes all the difference in the world when it comes to your success in sales. Thinking about closing the deal puts you in an entirely different mindset that allows you to have the right conversation to make it happen.

Your mindset is the difference between closing more business and losing it. We have identified three critical mindsets that top producers use to grow their business. They are:

1. Creation vs. competition
2. Openings vs. closings
3. Alliances vs. lone ranger

Creation vs. Competition

Too many sales executives go into sales calls trying to beat their competition instead of creating better results for their customers. To build a value proposition that is second to none, you must concentrate on generating better results rather than competing against the processes already employed by the client. This is what Scott Nadell, Director of Sales for a third party billing company in New York, does.

Scott called me and wanted to know how he could close more deals. It seemed as though every time he walked into a practice, the walls would go up and office managers and doctors would be rude and unwilling to listen. Scott was going in to tell them how great his system was and how he could save them time and money. He was a threat to peoples' jobs and nobody wanted to deal with him. Sound familiar?

Scott changed his approach from competing against what they are currently doing to having conversations on how partnerships with his company can produce better results. He created different mindsets that enabled his audience to want to hear what he had to say without feeling threatened.
 

Openings vs. Closings

After switching his mindset to one of creation, Scott then looked at how he presented his position when introducing himself to prospects. Instead of telling them how great he was, he provided actual statistics on how much money his company had successfully billed and collected for its clients. He positioned his company as a valued resource that helps practices increase their profits and revenues through an efficient billing and collection system.
But here is the catch! Scott did not do this in a one-sided conversation. He got the doctors and practice managers to talk first about where they wanted to take their practices and what goals they had identified for their billing systems. Once he figured out where their struggles were, he then presented his systems and results in the context of what was important to each particular practice. When the managers and doctors heard his pitch, they felt like it was fully customized to address their issues.
 

Alliances vs. Lone Rangers

Scott then decided to take the same approach when it came time to creating alliances with other parties, such as attorneys and accountants. He realized that being introduced to a new prospect by one of their trusted advisors greatly reduced the amount of time it took to gain his prospect's attention and interest. If your attorney says that you need to speak to a service provider who is going to help your business, you are going to have that conversation.

Scott always knew that this was important. What he did not realize is that you need to treat each alliance as a client. In other words, don't just ask them for referrals. Do what you do with the doctors: ask about where they are trying to take their businesses, then discuss how partnering with you can help them get there.

Today, Scott and his company are enjoying great results from operating with these three mindsets. They are closing new accounts and creating alliances with influencers in their industry who are opening a lot of doors for them.

Scott started seeing results initially in the quality of the conversations he was having, which led to more opportunities and eventually more business.

What mindsets do you operate from? For doctors to switch third party billing companies or to go to a third party biller, they need to hear a compelling reason. That only comes when you operate from the right mindset. 

Courtesy of: http://www.hbma.org/news/public-news/n_three-mindsets-for-growing-your-business-and-sales

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Choosing the Right Clearinghouse - Five Essential Qualities

An article by Bill Marvin from the July/August issue of HBMA Billing (www.hbma.org).
In the healthcare billing industry, the clearinghouse you work with has a huge impact on your business. The more efficiently your clearinghouse processes and returns your information, the faster you and your clients will get paid and the more payments you will collect. Therefore, knowing the right qualities to look for in a clearinghouse is crucial to the success of your business.

To gain insight into what billing services need from a clearinghouse, I interviewed Kevin Milam, owner of a company that does billing, consulting, and accrediting for clients across several states. We came up with five essential qualities to look for when researching clearinghouses to ensure that you are making the best decision for your business and your clients.

1. Knowledgeable and Immediate Customer Support

Having access to a knowledgeable, responsive customer service team is critical in any industry. For a billing service, waiting multiple days for an issue to be resolved can result in delayed payment, so choose a clearinghouse that allows you to log an inquiry 24/7 and that will respond to you within 24 hours. How can you tell for sure if a clearinghouse offers high-quality customer support? "Generally, if you receive immediate acknowledgement and responses to inquiries while you're researching a clearinghouse, you likely will receive the same treatment as a customer," says Kevin. Also, review the clearinghouse's commitment to customer service hours and responses in its contract. In most contracts, these performance elements are known as Service Level Agreements (SLAs) and are contractual commitments, sometimes with penalties.

2. Quick Claim Responses (Claim Status)

Once you submit claims to your clearinghouse, you should know within minutes which claims went through and which claims need to be corrected and resubmitted. "The longer you have to wait for claim responses, the longer it takes before you can correct any errors," says Kevin. "This delays cash flow for you and your clients and potentially leaves money on the table." Clearinghouses that tie claim status back to individual claims will save you time in the submission process.

3. Consistency and Accountability with 835s

You should receive an 835 and payment within a consistent timeframe so that you can post and reconcile your payments quickly. "With clearinghouses I've used in the past, I have received 835s weeks or even months after receiving the payments," says Kevin. "There was no consistency." When you can count on receiving 835s and payments within a day or two of each other, you and your staff won't waste time tracking down delayed 835s or payments for posting and reconciliation. Furthermore, the payment trace numbers or check numbers should re-associate with the 835s so that you can reconcile the payments more efficiently.

4. Efficient Claim Information

"It's not enough to have all of the claim information in your system," says Kevin. "You need to be able to use that information efficiently across multiple staff members at the same time." For example, if you can view a summary of all claim statuses on an 835, your staff can immediately identify which payments to post and which claims to reprocess. Additionally, your staff should have the ability to update the claim statuses as they reprocess claims or post payments, so that they don't duplicate any work done on the 835. This enables you to track all claim activity from a summary report or dashboard without wasting time looking at each individual claim.

5. Usability

For a billing service, it's key to be able to train your staff to use your system, especially as your staff changes or expands. Choose a clearinghouse with easy-to-use features like human readable claim responses and 835s; detailed and customizable reports hosted in a secure, private cloud; and a minimal number of clicks required to complete your workflow. "The steps required to process claims should make sense," says Kevin. "If you can't easily train your staff to use your system, it won't benefit you."

In addition, it is important to choose a clearinghouse that is accredited by the Electronic HealthCare Network Accreditation Commission (EHNAC). Some states and many payers will require you to use an EHNAC-accredited clearinghouse.

When you research clearinghouses, be sure to speak with existing customers, whom you can ask about each of these qualities. As the industry pushes for greater efficiency, it becomes even more important for your business to save time and money. Working with a clearinghouse that has all five of these qualities will help you to simplify your day-to-day processes, increase your cash flow, and help your business and your clients' businesses thrive.

 

Courtesy of: http://www.hbma.org/news/public-news/n_choosing-the-right-clearinghouse-five-essential-qualities

 

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Opportunities to Expand and Keep Your Business

By Steven Peltz, from the Jan/Feb issue of HBMA Billing

As a medical practice consultant, one the first areas of a medical practice that I evaluate is the billing department or billing company of a practice that has hired me. In my capacity as the president-elect of the National Society of Certified Healthcare Business Consultants (NSCHBC), I have had informal discussions with HBMA President Don Rodden, CHBME, about the consulting services that billing companies provide to practices, sometimes without understanding how important their role is to the practice.

I was introduced to HBMA by Government Relations Committee Chairman, Barry Reiter, CHBME. He and I have discussed the constant chaos that the healthcare delivery system is in and identified some of the opportunities that arise from that state. You may not know it, but many of you are already consulting, and if you have not set up your engagement contracts wisely, you are missing out both on revenue and having your client understand and appreciate all the value you bring to the practice. As practices merge and are acquired by hospitals, it is a good idea for your company to offer more than one line of service. Here are a few examples of what I do; you may want to consider adding these services to your company if you do not already offer them.

Over the years, I have established a benchmark of what a practice's accounts receivable (A/R) should look like. It is not cast in stone and is not fail proof, but it is a simple measuring tool that I use. I take the A/R temperature of all new clients and put it on a bar graph, then compare it to my benchmarks (see page 24). I then demonstrate to the potential client that by using the graph, their money is worth less the longer it is owed to the practice. I point out that either their billing company or billing department is not meeting the standard. I also break down the front end of the billing process and identify disconnects in the data collection process, such as: poorly trained staff, lack of reconciliation, monitoring, and the final decision with respect to collections.

Reducing the lifetime of debts that your company must collect begins at the point of service. Collecting co-pays at the time of each practice visit reduces postage, cuts billing staff time, and increases cash flow. Increasing the consistency of this front end collection means training the practice's staff to train the patients. For example, the front end staff may say to the patient, "Your co-pay today is $20" and then stop and wait. A more effective script for collecting co-pays may be, "Your co-pay today is $20, and we accept cash, checks, and credit cards. How would you like to pay?" A subtle but important difference, and while it will not work 100% of the time, it will result in increased revenue. Then, tell your client that you will monitor the success of their front office staff in collecting co-pays and refresh the front staff's training a few times a year. Finally, track the front staff collections on a monthly (or less frequent, but consistent) schedule and meet with your client enough times for your client to develop trust in you as a part of the management team.

When patients call to schedule appointments, do the front desk staff members ask for enough information to check insurance eligibility and acquire authorizations, when appropriate, before the visit?

Is there a daily, weekly, or monthly close that reconciles the cash, personal checks, credit card receipts, and insurance checks with the end-of day and end-of-week computer report and the bank statement? This is a simple way to make sure all the funds go into the bank and not into someone's pocket.

Does the office manager or billing department / company supervisor produce a monthly report that compares the charges and collections of the past month with the same month last year and two months before? This will spot and identify trends before they become problems.
During the first few meetings with your client, be prepared to bring something to the discussion that demonstrates the depth and scope of your knowledge and how your expertise will add to the success of the practice. For example, each year Medicare changes their codes; you could explain which, if any, impact the practice. If it is a primary care practice, establish a referral-based report. Identify how many dollars are sent out of the practice and to what specialties. Are there ways to recapture some of those dollars? Is the PCP or the specialist asking enough questions and documenting enough to code one level higher, if appropriate? I usually tell the owners(s) that the practice needs a preventative audit at least once every year and especially after a new provider is hired. When they ask why, I give them examples of other practices that have had to write checks back to payers.

When your client brings in a new provider, do you offer to credential the provider or bring in someone who can? Do you discuss ancillary sources of revenue that other practitioners use that can also be applied to that practice?

You probably already do between 80% and 100% of the above suggestions, but does the client understand how these services impact their practice? The point is whether your client knows that you provide these services. Yes, I know that they do not want to pay more for services that they think should be included, but that is not a reason to forgo informing them of all you do. Enhancing the services that you offer discourages clients from shopping for competing providers – it is much less expensive to keep a client than it is to get a client. Also importantly, by enhancing your services, you become more appealing to potential new clients when you make sales calls and offer to analyze their operational efficiency.

As a consultant, I either know the answer to the question or where to get it. You should be no different. With the constant change in the healthcare delivery system, you need to be constantly enhancing your product and empowering your clients with more opportunities.

 Courtesy of: http://www.hbma.org/news/public-news/n_a-reminder-opportunities-to-expand-and-keep-your-business

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What to Do When Services are Not Paid by a Commercial Payer

If a practice is contracted as a participating provider with commercial insurers and networks, it must pay close attention to the patient "Hold Harmless" sections of the agreements. Many agreements prohibit billing the patient for services that are unpaid due to the insolvency of a payer (which may be the insurer or a self-funded employer), when the payer deems a service not medically necessary, for lack of compliance with utilization programs, or for failure to file a claim in a timely manner. Some agreements even go so far as to prohibit a practice from having a waiver signed by the patient in which the patient agrees to be responsible in these circumstances.

The best way to protect a practice so that it can bill the patient for services not paid for by the plan is twofold:

1. Re-negotiate the language in agreements in the Member Hold Harmless provision, sometimes called "Billing the Patient," or the like, to more favorable language.
2. Implement a patient financial responsibility statement / waiver* and signature process so that your patients acknowledge their responsibility to pay during these circumstances.

In re-negotiating the contract language, be sure the terms reflect that it is "only when required by applicable law" that you will not bill the patient / member under the circumstances that the plan is insolvent or has determined that the billed services are not medically necessary. In many states, practices are bound by such provisions by state regulations, but only with respect to state regulated HMOs and certain fully insured or government plans. These plans are generally required by law to retain reserves that will pay claims for a matter of months should the plans become financially unstable.

The majority of the members / patients that practices see under most agreements are in self-funded plans that operate under the federal Employee Retirement Income Security Act (ERISA). These plans do not have the same regulatory reserve requirements as the plans discussed above, and the contract should reflect that a patient waiver for such plans can be used to hold patients financially responsible if a self-funded plan does not pay for any service. The risk of a self-funded plan going belly up overnight and not having funds reserved to pay recent claims is therefore much greater. If a practice signs a network agreement that says that it can never bill the member for services not paid for by the self-funded plan, even in the case of insolvency or when the plan determines the service to be medically unnecessary, then billing the patient is technically prohibited even when there is a waiver signed by the patient agreeing to pay for claims in these cases.

In revising your patient responsibility statement or waiver for patients covered under private payer plans, be sure to specifically include the patient's promise that he or she will be financially responsible, as allowed by applicable law, in the event that:

• His or her insurer or self-funded employer does not pay the claim in a timely and accurate manner
• The insurer or payer deems the service to be either not medically necessary or to be an excluded or non-covered service
• The payer or insurer denies the claim for lack of timely filing or adherence to utilization or payment policies
• A claim is prospectively or retroactively denied due to lack of eligibility or benefits

Although the practice is obliged to adhere to utilization management programs and payment policies in most agreements, many payers' programs and policies are not readily accessible, especially when leased networks are involved. The patient needs to be financially responsible and compliant with program requirements. When a multitude of claim administrators and employers are renting a network such as Multiplan, Galaxy, or Three Rivers Provider Network, each party leasing the network may have unique programs and policies that are not found on a central web site or portal. There can be some very good reasons to contract with leased networks, but these varying policies can make monitoring those who rent the networks more challenging. Sometimes these networks are less likely to modify the hold harmless language so as to appease all of their renting parties.

In addition to the hints provided above, when defining and administering the terms of the patient responsibility statement / waiver, the practice should be prepared to advise the patient in advance of denial, if it is aware that a service may not be covered. Provide the patient with the likely cost and payment terms that will be accepted, preferably in writing, including any prompt pay or hardship discounts that might apply. This type of communication can assist you in managing the patient's expectations and his or her commitment to timely payment. These extra steps can also add to the practice's compliance with the newly negotiated and more favorable hold harmless terms.

 

From the Jan/Feb issue of HBMA Billing by Penny Noyes http://www.hbma.org/news/public-news/n_what-to-do-when-services-are-not-paid-by-a-commercial-payer

 

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Compliance FAQs... How Much is Too Much?

How much information can a biller leave on an answering machine when calling for address or insurance updates?

Answer: Because the biller cannot know for sure who will listen to a message, even when calling a telephone number provided by the patient, it is wise to leave the minimum amount of information necessary to accomplish the reason for the call. Various legal concerns, including the HIPAA Privacy and Security rules, state that confidentiality and privacy laws and debt collection statutes and regulations can be implicated and should be taken into account.

A bare bones message may contain little or no revealing information while still accomplishing the task.

EXAMPLE 1: "This message is for [patient]. We are calling to verify your current mailing address (or insurance information) in order to bill for recent medical services you received. Please contact us at xxx-xxxx during office hours."

Here is another message scenario that gives minimal information.

EXAMPLE 2: "This is Medical Billing Office calling for [patient]. We need to contact you for an updated / corrected mailing address (or insurance information). Please call us at xxx-xxxx at your earliest convenience."

Various factors should be considered in deciding how to draft scripts or instructions for your staff regarding outbound messages.

• What is the purpose of the call / message?
• Who is the provider / client? Are they well known in the community?
• Do they practice in a sensitive specialty, such as family planning, mental health, etc.?
• Is there a reason you would need to disclose the client's identity or other detailed information at all?
• What would be the risk if someone other than the patient or a close family member heard the message?

If additional information would be helpful and would not unnecessarily reveal personal health information (PHI) or sensitive information, it can also be included in the message.

EXAMPLE 3: "This message is for [patient]. I am calling for the billing office at [General Hospital Radiology Group]. Please contact our office to update your mailing address (or insurance information)."

 

CMS has published FAQs that are generally related to this question. By analogy, they support the conclusion that a biller may leave a minimum amount of information on an answering machine to solicit a response and gather information to enable proper billing.

The official HIPAA FAQs can be found on the website of the DHHS Office of Civil Rights at www.hhs.gov/ocr/privacy/hipaa/faq/index.html.

 

From the Office of Civil Rights HIPAA website:

May physician offices or pharmacists leave messages for patients at their homes, either on an answering machine or with a family member, to remind them of appointments or to inform them that a prescription is ready? May providers continue to mail appointment or prescription refill reminders to patients' homes?

Answer: Yes. The HIPAA Privacy Rule permits health care providers to communicate with patients regarding their health care. This includes communicating with patients at their homes – either through mail, phone, or in some other manner. In addition, the Rule does not prohibit covered entities from leaving messages for patients on their answering machines. However, to reasonably safeguard the individual's privacy, covered entities should take care to limit the amount of information disclosed on the answering machine. For example, a covered entity might want to consider leaving only its name, number, and other information necessary to confirm an appointment, or ask the individual to call back.

A covered entity also may leave a message with a family member or other person who answers the phone when the patient is not home. The Privacy Rule permits covered entities to disclose limited information to family members, friends, or other persons regarding an individual's care, even when the individual is not present. However, covered entities should use professional judgment to assure that such disclosures are in the best interest of the individual and limit the information disclosed. See 45 CFR 164.510(b)(3).

In situations where a patient has requested that the covered entity communicate with him or her in a confidential manner, such as by alternative means or at an alternative location, the covered entity must accommodate those requests, if reasonable. For example, the Department considers a request to receive mailings from the covered entity in a closed envelope rather than by postcard to be a reasonable request that should be accommodated. Similarly, a request to receive mail from the covered entity at a post office box rather than at home, or to receive calls at the office rather than at home are also considered to be reasonable requests, absent extenuating circumstances. See 45 CFR 164.522(b).

 

Courtesy of:  http://www.hbma.org/news/public-news/n_compliance-faqs

 

 

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ICD-10 Physician Training Tips: Podcast

Podcast: http://www.physicianspractice.com/medical-billing-collections/icd-10-physician-training-tips

ICD-10 is just around the corner and your practice needs to start preparing. Part of that preparation must include physician training and efforts to increase physician engagement.

During her presentation at the AHIMA 2013 ICD-10-CM/PCS summit in Baltimore, Cindy Seel, director of education and training at HRS, shared seven steps health systems can take to get physicians prepared for the transition.

Later, she spoke with Physicians Practice about some of her key ICD-10 preparation and training recommendations for physicians.

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