Impatient about Patient Balances

As Opening Day approaches, we offer this intro: in baseball, a batter can reach first base in seven ways. The opposing team does what it can to ensure none of those ways happens.

In healthcare, the following are the five ways patients can owe money. To the best extent possible, you’ll want to ensure that none of these ways are successful:

• Copayments: revenue that should never be missed.
• Balances after insurance: what patients owe after their insurance reimburses.
• Co-Insurance: when patients are required to pay an amount to the provider as part of the patient’s coverage
• Out-of-network: whether it’s a fully OON situation or is only OON based on the procedures to be performed, patients will owe whatever the charges are for those procedures.
• Self-pay: there’s no insurance involved, and these patients are responsible for payment.

With so many ways to owe pre- and post-visit balances, it’s no wonder patients are often reported to be the third largest healthcare payer group in the US, behind only Medicare and Medicaid.

It’s also precisely why you need to ensure that you have access to the tools and services required for capturing every patient dollar regardless of how they’re owed. And to complicate things, remember that patients almost assuredly have multiple means.

ADS RCM and our AI-architected/rules engine-driven MedicsPremier platform, to which clients have unlimited access, puts our clients in a position of strength to capture every patient dollar and then support multiple ways for patients to make their payments.

• Display copayments while scheduling appointments or at any time in advance so that patients can be reminded about paying when they arrive.
• Access the Patient Responsibility Estimator while scheduling appointments; provide patients with a close estimate of what they’ll owe based on the appointment reason after their insurance reimburses, and then use it again as patients leave once their actual procedures have been performed. ?Then based on your financial policy, you can obtain an acknowledgment from the patient, eliminate surprises, and perhaps even get a partial or complete payment as allowable by their insurance payer.
• Get immediate eligibility verifications on scheduling appointments. Verifications will verify coverage to ensure it’s intact and alert about co-insurance. Our team then performs up to three more verifications before appointments to ensure nothing has changed.
• Know immediately when scheduling appointments if there are any out-of-network issues. Then,??display a list of providers who might be in-network for the patient. If it must be an OON appointment, you can invoke your financial policy, alerting the patient if the payment goes directly to them.
• Establish a payment plan/schedule if applicable for self-pay patients; the MedicsPremier system can be used for payment plans.

Use the Medics Patient Portal with its online credit/debit card payment option for patients to pay their balances due quickly. And our interactive balance-due texting option is ideal for reminding patients about what they owe.

Patients can pay directly through their texts, and you can track whether or not texts are opened.

Email statements are also available.?Text or email statements that can’t be delivered are automatically reverted to paper statements.

And then, patients are directed to call us if they have statement questions removing that time-consuming burden from your staff.

ADS RCM clients maintain remarkably low patient A/R rates because they can access such powerful features to protect their revenue in advance.

Bad News on Past-Due Medical Debts

According to a new Urban Institute report, more than one in seven nonelderly adults live in families with past-due medical debt.

Not surprisingly, medical debt especially impacts low-income families, with approximately two-thirds of those adults having incomes below 250 percent of the federal poverty line.

Hospitals are owed more of the past-due medical debt, with nearly three-quarters of affected adults owing at least some debt to hospitals. More specifically, 28 percent of affected adults owed to hospitals only,??and 45 percent owed to hospitals and some other providers.

With ongoing inflation and new financial concerns swirling about today, you must do everything possible to ensure patients pay their responsibility amounts. And you also want to know if your insurance claims are being submitted at their highest potential value (yes, there can be a difference). That E/M coding is maximized, and that NCCI editing is spot-on to avoid unnecessary denials. Prior authorizations were obtained if needed, eligibility verifications were performed, and that out-of-network alerts were received all prior to appointments and, ideally, while scheduling those appointments.

Click here for the report.

ADS RCM, our team of billing experts, and our AI-architected/rules engine-driven MedicsPremier platform helps ensure maximized revenue and productivity for clients.

Speaking of E/M Coding…

Correctly coding for E/M – “correctly” meaning “in your favor” – has accounted for a moderate decrease in the payment gap between primary care and specialty physicians.

According to a study published in JAMA, the evaluation and management (E/M) payment policy changes implemented in 2021 resulted in higher Medicare reimbursement for most physicians.

Why should primary care physicians care more about E/M? Because Medicare payment policies have historically undervalued E/M visits which are common in primary care settings, leading to lower reimbursement for primary care physicians compared to specialists.

Click here for the JAMA study, and know that ADS RCM has an eye on your E/M coding!

Did We Mention E/M Coding?

Providers can bill outpatient E/Ms at five different levels on claims based on the complexity of the visit. At issue is how

Outpatient visits are being billed at higher levels, which causes increased healthcare spending, which causes concerns about up-coding.

In a nutshell, Level 1 visits have the lowest complexity, shorter encounter times, and require less complicated medical decision-making. Level 5 visits comprise the most difficult cases, need more time, and involve complex decision-making. Levels 2 - 4 are in the complexity mix on a graduating scale. Not surprisingly, payers typically reimburse providers more for more complex cases.

It’s the AMA that provides the guidelines on visit complexity. As alluded to, the problem is that providers could inadvertently up-code.

At issue is how the cost of higher-level claims is growing faster than that of lower-level claims.

If outpatient visits were billed at the same levels as ten years ago, physician office and emergency department E/M spending would have been 4 percent lower in 2021. If visits were billed at 2004 levels, emergency department spending would be 11 percent lower, and physician office spending would be 10 percent lower in 2021.

E/M coding is an art and science unto itself. If you’re involved in complex cases requiring a lot of medical decision-making, you should maximize your E/M coding. But if coding is too high for certain encounters, it’s up-coding.

We provide the alerts needed to ensure your E/M coding is correct and that you maintain your coding lane. That also pertains to NCCI edit alerts for whenever claims should be combined into a master claim vs. submitting them separately and risking unnecessary denials.

Click here for the report details described above.?

Disclaimer:?Articles and content about governmental information, such as CMS, Medicare, and Medicaid, are presented according to our best understanding. Please visit www.cms.gov if clarifications are needed. We are not responsible for typographical errors or changes that may have occurred after this newsletter was produced. Visit www.adsc.com to view our most up-to-date information.?