Third Party Reimbursement Training

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Third Party Reimbursement Training
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Julia Hidalgo, ScD, MSW, MPHPositive Outcomes,
Inc.Harwood MDwww.positiveoutcomes.netjulia.hid
algo_at_positiveoutcomes.net(443) 203 - 0305
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• Planning Committee
• Aubrey Arnold
• Gayle Corso
• John Eaton
• Theresa Fiano
• William Green
• Deidre Kelly
• Syd McCallister
• AHCA
• Heidi Fox

• HRSA HAB Project Officers
• Johanne Messore
• Yukiko Tani
• TPR Trainers
• Curt Degenfelder
• Marilyn Massick
• Michael Taylor

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Ground Rules

• I do not represent HRSA, CMS, or AHCA
• Let me know if you do not understand
• We can share our feelings at the end of each
  section
• You will be rewarded for staying awake
• Shut off your electronic devices
• A 15 minute break means 15 minutes!

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Overview of Todays Session

• Overview regarding organizing patient/client
  charts, basics of billing, developing billing
  systems
• Additional training modules and materials are
  available on website
• Real life examples will be used
• Resources for more in-depth information are
  identified
• Each section includes training and discussion
• Train the trainer approach is used
• Please follow-up by email with additional
  questions
• Focus of the training is on beginning to
  intermediate skills
• Advanced training and TA are available

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What is third party reimbursement (TPR)?
TPR is receiving payment from a source other than
the patient for services provided to patients by
a provider. This other source is the third party
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Constructing an Effective TPR Strategy
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HRSA Grant Funding Versus TPR

• The CARE Act is considered by the HIV/AIDS Bureau
  to be the payer of last resort
• This requirement is subject to audit
• CARE Act grantees have been audited
• Grantees and subgrantees should not rely on grant
  funds as their sole source of revenue
• HRSA grant funds are finite because they are
  capped in annual appropriations
• TPR is driven by patient service and volume
• Funds from TPR should be used in addition to HRSA
  grant funds

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The Role of a Grantees Sponsoring Organization

• Communicate the availability and value of TPR
• Grantees and subgrantees (i.e., contractors)
  should agree upon billing and collections
  responsibilities and procedures
• Grantees should request periodic accounting of
  collected TPR payments, as appropriate
• These payments should be reported as grant income
• Grant income should be retained by direct service
  provider grantees or contractors
• Grantees should develop and implement clear,
  adequately documented processes for CARE Act
  invoices for Title I and Title II

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Documenting CARE Act and Other Funded Services
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Health and Case Management Record Basics

• The record is the core element of a visit or
  other unit of service
• It is a systematically organized record of a
  patients total care
• Everyone who records progress of care in the
  record should follow the same note writing format
• Policies and procedures dictate its organization
  and use
• Creates a verifiable record of services provided
  for third party payers and other interested
  parties (QI, accreditation, etc.)

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Health and Case Management Record Basics

• The record is the primary instrument for planning
  care
• Forms the basis to bill and pay for care
• Documentation in the record can be reviewed by
  third party payers
• Records are legal documents that assist in
  protecting the interests of the patient,
  facility, and providers
• They are considered to be more reliable than an
  individuals memory about events
• They can be used in court or for other legal
  matters
• They can protect you in a law suit

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Record Documentation

• Documentation provides the who, what, when,
  where, why, and how of patient care
• Regardless of the complexity of documentation,
  records must be comprehensive enough to meet
  regulatory, licensing, accreditation, legal,
  research, and patient care needs and purposes
• Record notes must be comprehensive enough to
  support evaluation and management code assignment

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Record Contents

• Date and time of service
• Place of service
• Chief complaint/presenting problem
• Objective findings
• List of tests/labs that are ordered and lab
  results
• Diagnoses
• Therapies administered and medications provided
  or prescribed
• Preventive services provided
• Disposition and patient instructions
• Providers name and title
• Length of the visit (e.g., minutes required to
  document time-specific procedures)

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Minimum Records Processes

• Develop and implement a process addressing the
  use of standard forms including
• Responsible parties for form development and
  revision
• Form approval process
• Definition of timeframe for periodic review and
  revisions of forms
• Consistent use of forms across sites

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CMS/AMA General Principles of Record Documentation

• An individual record is established for each
  person receiving care
• The patients name should appear on every page
  with their unique identifier (patient record
  number)
• The record should be complete and legible
• Documentation of each encounter should include
• Reason for the encounter
• Relevant history and physical examination
  findings
• Prior diagnostic test results
• Assessment, clinical impression, or diagnosis
• Care plan
• Date and legible identity of the observer

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CMS/AMA General Principles of Record Documentation

• If not documented, the rationale for ordering
  diagnostic and other ancillary services should be
  easily inferred
• Past and present diagnoses should be accessible
  to the treating and/or consulting physician
• Appropriate health risk factors should be
  identified
• The patients progress, response to, and changes
  in treatment and diagnosis should be documented
• The CPT and ICD-9-CM codes reported on the health
  insurance claim form or billing statement should
  be supported by the documentation in the medical
  record
• If its not legible, its not there
• If its not there, it wasnt done

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Universal Record Standards

• All clinical information pertaining to a patient
  is kept in the record and must be readily
  available any time the facility is open
• Multiple sites
• Filing systems
• Records elsewhere radiology, counseling, etc.
• Standards apply across all settings and are
  compiled from JCAHO, NCQA, AAAHC, Medicare, and
  Medicaid

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Universal Record Standards

• Information should be recorded by the provider at
  the time of care
• At least on the same day
• The longer the delay, the lower the quality of
  the entry
• All staff should use the same set of approved
  abbreviations and symbols
• All entries must be dated, timed, chronological,
  legible, and signed in non-erasable blue or black
  ink by the provider with his/her credentials
  noted after their name
• No blank spaces in between entries
• Corrections can only be made with a new
  entry-cross out and initial

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Reimbursement and Records

• Physicians and mid-level providers can make
  entries in the record and may generate charges
  during a patient visit
• All payers have specific guidelines about how to
  submit claims for non-physician charges
• Some payers may credential non-physicians to
  allow charges to be submitted under their own
  provider number
• Others only allow billing under a physician
• Whatever the rules, be sure that your health
  record documentation backs up the billing

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Reimbursement and Records

• Charges can be generated based on office visits,
  consultations, procedures, diagnostic tests,
  X-rays, injections, vaccinations, and/or supplies
• Supporting documentation (including who provided
  the service) has to be located in the progress
  notes, laboratory reports, X-ray reports, or
  diagnostic service reports
• If services are provided in multiple sites (e.g.,
  exam room and lab), charges have to be collected
  and organized for billing purposes
• A data collection form is the best way to do this

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Why set-up record policies and procedures?

• Maintaining record policies and procedures is
  essential to protect your program and patients
• Licensing and accrediting bodies, as well as
  governmental entities, require them
• Your policies and procedures dictate how health
  information will be maintained and protected
• Your policies set the basis for your legal record

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Minimum Record Policy Elements

• Confidentiality policies and procedures
• Chart organization sections, forms, and their
  order in the chart
• Including specifications of what constitutes a
  complete record
• Record maintenance, storage, retrieval access to
  and archiving, backing up, security, and
  destruction
• Patient compliance informed consent and
  authorization to release information
• Health record documentation practices who, how
  and when entry authentication correcting the
  record
• Sanctions or progressive discipline policy for
  staff who do not make proper entries into records

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Set Your Record Audit Policy

• Internal record audits should be performed as
  part of your programs QA procedures
• Internal review allows problems to be identified
  and corrected before someone else does it for you
• Record internal audit policies should address
• Audit content
• Auditors
• Audit timeframes, breadth, and scope
• Levels of review
• Audit types
• Qualitative or quantitative deficiency analysis
• Detailed audit process

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Records Policy Implementation

• When policies are developed, be sure
• Input on the content has been received from all
  levels of staff, as appropriate
• Staff are trained on the content and retrained
  annually
• Maintain training session attendance records
• All new employees should be oriented upon hire
• All staff training should be documented
• Staff should have easy access to relevant
  policies
• Computer access is ideal

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Step-by-Step Billing Process
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Billing Process
Generate Sign Bill
Contact Payer
Submit Bill
No
No
Payment?
Pend/Denial?
Yes
Yes
Deposit
Correct
Post Payment
Re-submit
Bill Patient if applicable
Charge Entry
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Components of Bill Generation

• Schedule appointment
• Collect as much patient information as possible
• On-site registration
• Collect and verify outstanding patient
  demographic and insurance information
• Conduct financial screening, as necessary
• Create or have patient health record available
• Generate encounter form
• Provider encounter form
• Provider completes encounter form and health
  record, both of which go to coding

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Components of Bill Generation

• Coding a claim
• Coder verifies record notes, assigns appropriate
  codes, completes encounter form, and forwards it
  to billing department
• Generating a bill
• Billing department books appropriate service
  charge and produces bill based on completed
  encounter form
• Submitting a claim
• Bills are aggregated to form a claim, claim is
  attached to transmittal sheet identifying
  included bills, and both are submitted to third
  party payer

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Common Billing Forms

• The CMS1500 is the standard form used to bill all
  third party payers for professional services
• It must be completed accurately
• Timely collection of third party reimbursement
  depends on this form
• The CMS1450 (UB-92) is the billing form used for
  hospital-based outpatient care

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CMS1500 Top of Form
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CMS1500 Bottom of Form
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Code Sets

• Coding transforms descriptions of diseases,
  injuries, conditions, and procedures from words
  to alphanumerical designations
• The purpose of coding is to utilize code sets
  (ICD-9-CM, CDT, CPT, DSM, HCPCS, DSM) to classify
  patient encounters
• The actual code set used is determined by
• Healthcare setting
• Regulatory agency
• Reimbursement system
• Approved HIPAA transaction code sets
• ICD-9-CM, HCPCS and CPT are the primary coding
  systems that are used to determine reimbursement
  in the United States and selected under HIPAA

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International Classification of Diseases (ICD)

• ICD-9-CM has two volumes of diagnosis codes and
  one volume of procedure codes
• Resources for ICD
• Coding Clinic is a newsletter containing coding
  advice
• It is published quarterly and helps you keep up
  to date with ICD-9-CM
• Coding Clinic is agreed upon by a wide variety of
  parties and is considered authoritative
• Call 1-800-261-6246 to subscribe

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Sample ICD-9-CM Codes
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Current Procedural Terminology (CPT)

• Owned by the AMA and designed to facilitate
  communications between physicians, mid-level
  practitioners, and third party payers
• Codes represent procedures and services performed
  by clinicians and some codes for other staff
• Contains evaluation and management (E/M) codes
• To help with CPT coding, the AMA publishes a
  monthly newsletter called CPT Assistant
• Call 1-800-621-8335 for subscription, or go to
  http//www.ama-assn.org/catalog
• CMS, Medicare carriers, and fiscal intermediaries
  publish transmittals and bulletins about CPT
  coding to guide you in their use

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Sample CPT Codes
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Healthcare Current Procedural Coding System
(HCPCS)

• HCPCS Level II Codes represent supplies,
  materials, injectable medications, DME, and
  services
• Used mostly for ambulatory care and is a three
  level system
• Level I is the CPT code
• Level II codes are developed and maintained by
  CMS and updated quarterly
• They are used primarily for reporting purposes in
  ambulatory care claims processing
• Level III codes are for new procedures, devices,
  and services not in Levels I and II
• Defined by fiscal intermediaries and vary by
  location or payer
• HCPCS useful information at www.cms.gov

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Sample HCPCS Codes
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Other HIPAA Standard Code Sets

• Code on Dental Procedures and Nomenclature,
  Second Edition (CDT-2)
• Developed and maintained by the American Dental
  Association to record dental procedures
• Diagnostic and Statistical Manual of Mental
  Disorders, Fourth Edition (DSM IV)
• Developed and maintained by the American
  Psychiatric Association to code diagnoses made by
  mental health and substance abuse treatment
  providers
• National Drug Codes (NDCs)
• Developed and maintained by the Food and Drug
  Administration to report prescription drugs in
  pharmacy transactions and some claims by health
  claim professionals

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Coding Process

• The process of who does the coding may vary among
  settings
• However, the function of assigning codes does not
  change
• Providers and coders take clinical information
  (e.g., diagnostic terms, procedure descriptions)
  and assign a code to each one according to
  official rules
• Coders would take this clinical information from
  the providers portion of the health record
• The provider is responsible to record proper
  information
• Coding professionals do not make assumptions or
  use personal preferences
• Coding guidelines absolutely prohibit this

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Coding Tips

• Documentation must substantiate the bill
• The note should back up the code chosen, and vice
  versa, or you can lose reimbursement
• Coding is a joint effort between the clinician
  and coder to achieve complete and accurate
  documentation, code assignment, and diagnostic
  and procedural coding
• ICD codes labeled not elsewhere classified
  (NEC) or not otherwise specified (NOS) should
  be used only when the documentation in the record
  does not provide adequate information to assign a
  more specific code

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More Coding Tips

• Code to the highest level of specificity when
  applying codes (i.e., use the 4th or 5th digit if
  they exist)
• Do not code diagnoses documented as probable,
  suspected, or rule out as if the diagnosis is
  established
• Guidelines for these were developed for inpatient
  reporting and do not apply to outpatients
• You have to code the symptoms, signs, abnormal
  test results, or other reason for visit if no
  diagnosis is established at that time
• When no definite condition or problem is
  documented at the conclusion of a patient care
  visit, the coder should select the documented
  chief complaint or symptom

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Evaluation and Management (E/M) Coding

• All physicians, regardless of specialty, may use
  any E/M service code
• History, examination, and medical decision-making
  are the key elements when determining a level of
  service
• There are different codes for new and established
  patients
• E/M codes encompass wide variations in skill,
  effort, time, responsibility, and medical
  knowledge required for diagnosis and treatment
• Includes private/clinic office visits or
  hospital-based outpatient visits and other types
  of services provided by physicians and mid-level
  providers

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Coding and Reimbursement

• Coding errors can result in delayed, incorrect,
  or no payment
• With the added scrutiny of the Office of
  Inspector General and others, it is increasingly
  more important to minimize errors that can result
  from incomplete documentation or inappropriate
  use of codes
• Patient records have to include documentation for
  medical care, diagnostic tests, procedures and
  all other services submitted for payment

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Coding Audit Triggers

• On Medicares Current Hit List
• Excessive use of higher-level E/M codestoo much
  use of 99215
• Billing for consultations on established patients
  for minor diagnoses that do not support this
  level of service
• Billing for excessive repetition of lab tests
  when results are typically normal for that
  patient
• Upcoding and overutilization billing for office
  visits, especially when services were not
  medically necessary

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TPR Collections Step-by-Step
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Billing Process
Generate Sign Bill
No
No
Yes
Yes
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Collecting Third Party Payments

• Remittance Advice (RA)
• Third party payer forwards a RA to billing
  provider
• RA is usually accompanied by an Explanation of
  Benefits (EOB) form and a check for paid bills
• Deposit payment deposit payment immediately
  upon receipt
• Post payment payments made on outstanding
  amounts should be posted to patient accounts

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Collecting Third Party Payments

• Bill secondary payer
• As appropriate, bill secondary payer (s) for
  remaining patient balances (or coordination of
  benefits)
• Bill patient
• After payment from a secondary payer is
  received, bill patient accordingly
• Analyze pended and denied bills
• Analyze RAs and EOBs to identify and resolve
  correctable billing errors
• Resubmit corrected bills

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Remittance Advice (RA)

• The RA, or remittance statement (RS), is a
  written notice from a third party payer
• Itemizes submitted bills
• Identifies the payment amount for each submitted
  bill
• Gives the payment status of each bill (paid,
  pending, or denied)
• For each bill, the RA also shows
• Providers name and number
• Date of service
• Patient name and insurance ID number
• Service description, coding and billed charge
• Amount paid or payable for billed service (s)
• Patient deductibles or co-pays
• Payment status

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Remittance Advice (RA)
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Explanation of Benefits (EOB)

• Provider and patient identification
• Dates of service, procedures, and charges
  submitted
• Disallowed charges and explanation (usually
  codes)
• Allowed charges and explanation (usually codes)
• Deductible (if applicable) and year to date total
• Co-pay, if any
• Amount payable by the payer
• Identifies incorrect billing information that can
  be perfected and resubmitted
• Highlights ineffective operating procedures for
  collecting patient and service data used in
  billing so they can be modified, as needed
• Identifies the need for staff training on data
  collection and billing

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Explanation of Benefits (EOB)
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Bill Tracking and Adjustment Activities

• Essential bill tracking and adjustment functions
• Provider productivity
• Analysis of coding
• Frequency of illnesses
• Frequency of chronic versus acute illness
• Analysis of cost of care
• Account aging
• Cost center income and expense
• Profit and loss (yes, even in not-for-profits)
• Status of reimbursement transmittals/claims
• Bill tracking and adjustment activities are
  essential to maintain adequate cash flow
• Adding computerized tools can help with tracking
  and management, thereby improving cash flow

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Overview of the Claims Payment Process
Patient ID Match?
No
Yes
No
Yes
No
Yes
Yes
No
Yes
No
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Overview of the Claims Payment Process

• Payer scans the claim for a match with their
  database
• Claim procedure codes are checked
• Procedure codes are compared to claim diagnosis
  codes to confirm medical necessity
• Claim checked against previous claims
• Claim is checked to determine if another payer
  has responsibility to pay
• Allowed charges are calculated
• Deductible, if any, is calculated
• Co-pay, if any, is calculated
• EOB form is created
• EOB and payment is sent to provider

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Rejected Bills

• Payable bills can be rejected due to correctible
  errors
• It is important to track rejected bills to
• Identify improvements in billing and collection
  processes
• Highlight correctable program operations and
  billing problems
• Assess performance of billing staff
• Get additional revenue
• Some bills are rejected because they are
  un-payable
• Other bills are rejected because the claim was
  completed incorrectly or contained incorrect data
• Electronic bill submission, either internally or
  through an outside firm, can reduce rejections
  and expedite payment

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Common Reasons for Rejected Bills

• The patient not on file
• The bill is for non-covered services
• The procedure not medically necessary
• Out-of-network provider (rejected or reduced
  payment)
• A required preauthorization was not secured
• The patients coverage was terminated prior to
  date of service
• Other payer responsible

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Automation
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To Computerize or Not

• HIPAA requires electronic claims submission
• Billing and collections effectively require
  on-going management
• It is advisable, although not necessary, for a
  very small operation to computerize the data you
  need to collect
• General benchmark
• lt 10,000 visits annually manual system
• gt 10,000 visits annually computerized system
• Billing software vary in cost and training
  requirements
• Look before you leap

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Building Your TPR Team Tips in Reviewing Your
Staff Responsibilities
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Staff Responsibilities Registration Clerk

• Constructs patient health records before visits
• Has records available when patients arrive
• Ensures patients arrive at your program and sign
  in
• Registers arrival time
• Ascertains if insurance status or address have
  changed
• Ensures patient demographic data is correct
• Handles appointment reminders by calling patients
  or preparing reminder cards
• Clerk may
• Record the patients chief complaint
• Complete forms in the health record with
  demographic data
• Explain co-payment or deductible to patient and
  collect the cash or charge to credit card
• Transcribe codes to face sheet or a super-bill
  based on the patients chief complaint (if
  trained by your coder)

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Staff Responsibilities Coding Staff

• Encounter forms typically allow providers to
  check off item(s) on the forms that list many
  visit/procedure options and diagnoses, with the
  corresponding codes
• The medical visit level and diagnoses and
  procedures are taken from the encounter form,
  coded, and entered into a billing system
• Coders should ensure corresponding notes are in
  the record
• If coding notes, obtain health records, encounter
  form(s), or charge slip(s) and determine codes
• Enter codes into billing system if they assigned
  the code, otherwise this is a billers function
• If coding staff are not entering information
  directly in a computer program, a manual log
  sheet can be used
• Verify accuracy of date and place of service
• If billing software is available to execute
  claims, coders and then billers initiate the
  billing process
• Physical layout is important for coders to be
  able to be most effective, they need to
  concentrate

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Staff Responsibilities Billing Staff

• Charges or fees are then applied by the biller
  and CMS1500 claim forms are generated
• Verifies that all services provided were coded
• Matches encounter slips to appointment register
• Enters charges for services and generates bills
• Completes claim transmission and submits claim in
  a timely manner
• In small organizations the biller and coder can
  be one person

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Staff Responsibilities Accounts Receivable (AR)
Staff

• Posts, or records, the payments received from the
  payer
• Reviews Remittance Advice for
• Inaccurate information
• Adjustments
• Pended bills
• Denials
• Examines the EOBs to identify reasons for payment
  delays
• Communicates each reason to the provider, coder,
  or biller, as appropriate
• If payment is banked by electronic fund transfer,
  this reduces days in AR
• AR staff should know the date these deposits
  should be made and ensures the transactions occur
• Claims should all be paid within specific time
  limits
• AR staff should track or project payment dates
  and analyze this information to identify slow
  payers
• Provide input into fee schedule changes

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Staff Responsibilities Finance Staff

• Oversees all financial transactions, including
  billing, coding and collections
• Posts cash to the accounting system
• Produces cash flow reports, including aged AR,
  days in AR, and dollars in AR
• Regularly reports performance to CEO and board of
  directors
• Periodically audits coding and billing practices
  and ensures staff compliance with appropriate
  internal controls

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ReimbursementInfrastructure
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Constructing a Billing Department

• Well-trained intake/registration, coding, billing
  and collections staff, as well as adherent
  providers, are essential for success
• It is important to remember billing begins with
  the first contact by the patient
• This is their point of entry into service
• Consider billing process and functionality when
  making staffing decisions

70
Constructing a Billing Department

• For those of you who do not currently bill
• To decide on a plan to go forward
• Analyze who currently handles
• Scheduling
• Intake and registration
• Eligibility verification
• Creation of records
• These staff members can work collaboratively to
  create an effective billing department which
  integrates front desk, coding, billing, and
  claims submission functions

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Re-engineering a Billing Department

• For those of you who currently bill
• It is a good time to get the entire front and
  back office together and go over all of your
  functions
• Ensure everyone is on board with the philosophy
  that you need to be paid for what you do, and
  their connection to the payment cycle
• Review everyones functions while together to
  ensure that everyone understands the jobs that
  others do
• Be sure everyone understands they are an
  essential piece of an important process
• Cross-train everyone, plan for vacancies and
  vacation

72
Constructing a Billing Department

• Before you meet with all staff, review financial
  and demographic data that are currently collected
  to identify information gaps in your data
• If currently billing
• Pick one important issue/problem, and teach
  people how to flowchart the current process
• Then, together, develop one ideal process
• For those not currently billing
• Develop flowcharts documenting optimal patient
  flow processes and supporting administrative
  functions
• Design a physical office layout around the
  optimal
• Create tracking tools to ensure same problems do
  not recur

73
Billing and Collections Processes Implementation

• For agencies newly billing
• Now you are ready to conduct a simulation of the
  entire billing process from patient registration
  to payment posting and refine, as necessary
• For agencies currently billing
• Be sure to pilot your solutions first, and then
  implement them on a full scale
• Work out the bugs
• If your program does not have a provider number
  (s) and/or claims transmission authorizations,
  apply for these now
• Test transmission capability before submitting
  the first real claim

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Qualified Coding Staff

• Coding professionals are trained and often
  certified
• Beginning coders skills and credentials are
  adequate for primary care or freestanding
  outpatient settings
• Two organizations award coding credentials
• American Health Information Management
  Association (AHIMA)
• American Academy of Professional Coders (AAPC)
• Both have national credentialing exams

75
How do we estimate our financial return from TPR
billing and collections?

• Three types of information are essential to
  estimate your return
• Patient base
• Services offered
• Service volume

76
What is your patient base?

• Identify prevalent insurers for your patient
  population
• Learn their payment rates, what services each
  plan covers and under what circumstances
• Evaluate your patient population to identify
  uninsured clients versus individuals eligible for
  Medicaid, other public programs, and commercial
  insurers

77
What billable services does your HIV program
offer?

• Insurers vary in covered services, authorized
  providers, and payment rates
• Adjust your operations accordingly
• Hire Nurse Practitioners (NP) rather than RNs
  because NPs are billable
• Case management may be a covered service
• Charge for services that were previously provided
  at no charge

78
What is your service volume?

• A shift in perspective may be required
• Fee-for-service reimbursement and all inclusive
  rates are driven by the number of encounters or
  services provided
• Managed care capitated payments are driven by the
  number of patients enrolled with the provider

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Alternative Billing Arrangements Partnering

• Alternatives exist if the costs of developing
  internal billing infrastructure are prohibitive
• Collaboration with complementary organizations
• Buying into a common computer system, with a
  firewall to protect your organizations autonomy
  and information
• Share staff to access greater expertise than you
  might afford on your own
• Leveraging technical and financial resources

80
Alternative Billing Arrangements Outsourcing

• Do we build or buy our own billing systems?
• Companies exist that can handle all of the
  registration, billing, and collection processes
  by providing experienced on-site staff
• Billing services can
• Speed up payments through efficient processes,
  helping to improve cash flow
• Reduce rejected claims by catching billing errors
  during front-end editing
• Stay current with any changes in payer billing
  requirements
• Produce reports tracking billing performance

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Staffing and Patient Flow

• Consider patient flow and your space needs and
  construct your design layout accordingly
• Maximizing patient flow is the key
• Processes to consider include
• Constructing charts
• Scheduling patients
• Verifying their insurance
• Collecting copays
• Handling walk-ins
• Telephone calls
• Making referrals
• Level of staff training on your software
• Understand what your processes are, if they deter
  or enhance patient flow, and aim for no waits/no
  delays
• Map the entire process so that you can be sure
  that staff can carry a task to completion

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Staffing and Patient Flow

• Cross-trained staff should know when to jump in
  and help and be trained in troubleshooting
• To start your process mapping, gather some
  information
• Number of incoming and outgoing calls per day
• Number of visits per day/total and totals by type
• How many individual people call in by type
  -patients/ referrals/ pharmacies, etc.
• How many walk-ins per day - patients and others
  (sales people)
• Number of other interruptions, e.g., audits,
  deliveries
• Frequency of diagnoses (severity of illness)
• Service volumes, e.g., number of blood draws per
  day
• Number of new versus established patients seen
  per day
• Vacancy rates/absentee rates for all staff
• Number of charts constructed per day

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Billing and Collection Processes Implementation

• Train all of your staff, including providers
• All policies and procedures relating to coding,
  billing, health and other record management and
  accounting
• Federal/state and local regulations and new
  regulations, as they evolve
• Corporate compliance
• HIPAA requirements, general fraud and abuse
  issues
• Documentation
• Confidentiality and security
• Coding requirements, such as E/M code rules and
  prohibitions on up-coding/double billing
• Third party payer expectation

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Implementation Staff Education

• All staff need education
• Concentrate on provider and front office staff
  concurrently
• Keep providers coming by making training topical
  and relevant to what they do on a daily basis
• Keep training limited to 30 minutes per session
• Provide follow-up to training by documenting
  results of what was learned
• ALWAYS follow policies and procedures as written
• If you do not, then revise the policies
• Motivate staff to come to training
• Reinforce the consequences of inadequate
  documentation

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Other TPR Modules on Website

• Visit www.positiveoutcomes.net for additional
  training modules
• Automation of Records and Billing Functions
• In-depth Coding and Documentation Practices
• In-depth Billing and Collections Management
• Corporate Compliance
• Credentialing
• HIPAA