Essential Billing Benchmarks for 2021
Here are three billing benchmarks that LRS recommends being aware of at all times:
Denial/First Pass Payment Rates
How many denials are you receiving and how many claims are paid on the first submission? Many factors go into these metrics including accuracy of patient intake and registration information, correctness of insurance verification and authorization information, and how claims are being submitted per payor guidelines. A very efficient practice will have a denial rate under 5% and a first pass claim rate higher than 95%.
Percentage of Receivables over 120 Days
How quickly are you collecting the money you are owed? You should be aiming for less than 10% in the 120+ aging bucket. There are always going to be issues with specific claims but a healthy practice has about 75% of their AR in under 60-days outstanding.
Payer Mix/Expected Revenue per Payer per Visit
Who are your top 5-10 payers? What are they paying you per visit? Your overall cashflow is very dependent on your payor mix and what each payor is paying you per visit or per unit on average. This is an important metric every practice should monitor closely. Maybe it is time to try to renegotiate contracts, to consider going out-of-network with some insurances or maybe it’s time to use your marketing dollars more strategically.
These are only a few of the metrics you should be reviewing on a monthly basis. Do you see room for improvement in your practice? Contact us today at hello@lincolnrs.com to see how we can help you improve these essential benchmarks.
Fighting the NCCI Edit Denial Wave
As of October 1st, CMS has reinstated many of the procedure-to-procedure edits, which are more commonly known as the National Correct Coding Initiative Edits (NCCI edits). This rule was actually deleted earlier this year, however, it is effective again for PT, OT and speech outpatient therapy services. We are seeing denials for NCCI edit-related issues come in at a rapid pace from many insurance companies especially when it comes to the use of 97530. Your practice is likely facing this same issue.
What can you do to minimize these denials, ensure you are catching them on EOBs, and appealing them successfully?
1) Make sure your EMR is set up properly: Your EMR can be your best defense when it comes to adding the 59 modifier to appropriate codes that are separate and distinct. Check within your company, clinic, and carrier settings to ensure they are set up with the proper modifier functions.
2) Make sure your documentation is correct: If you are performing truly separate and distinct services, a therapist's documentation needs to reflect this. Even with the 59 modifier attached to the codes, insurance companies are still denying or requiring additional documentation. At LRS, we provide strategic coding audits to evaluate a therapist's documentation to ensure that they are meeting the standards that insurance companies require regarding reimbursement as well as compliance and regulatory requirements.
3) Make sure you are analyzing every single EOB: More times than not, insurance companies adjust bundled codes and do not deny them. If your billing team is not looking strategically at EOBs, they are likely allowing this code to be adjusted off instead of marking it as denied. This can be causing your practice a significant amount of money.
4) Make sure your appeals process is up to speed: Set up a fluid and traceable communication process between your billing department and your therapists. Communicating in real time will allow your billing department to be agile and will lead to comprehensive reimbursement.
5) Make sure you are regularly checking reimbursement rates at the code level: This will help you flag any potential issues and investigate lags before they are problems.
Do you think you are missing the payments earned for the care that you deliver? Could a quick spot audit help? Could your appeals process use some standardization? Contact LRS today to see how we may be able to help you improve!
No Surprise Patient Balances: Why Verifications Matter!
Insurance verification and authorizations play an essential role in avoiding denials and patient ineligibility for services. They are also a key component in your customer service.
While it is the responsibility of a patient to know their benefits, we are all aware patients often do not even know what a deductible is - let alone how much they have remaining on it. If you don't present this information at the time of service, you could be dealing with an angry patient when they receive their bill for treatment down the line.
What Does the Insurance Verification and Authorization Process Entail?
There are several things that should be obtained when an insurance verification is completed. These include: payable benefits, co-pay amounts, co-insurance amounts, deductible amounts, effective date of plan, additional coverage details, whether authorization (or prior authorization) is required, confirmation of claims address, the patient's yearly maximum, etc.
While some insurances allow you to check benefits online and they can be completed fairly quickly, other insurances require up to an hour (!!) spent on the phone to obtain benefits. This can leave your front desk or office manager on the phone when they could (and should!) be interacting with the patients in your office.
By outsourcing your insurance verifications and authorizations you can:
Speed up approval process
Simplify your workflow
Improve payment and collections
Improve staff productivity
Improve customer service
...among many others!
At LRS, we have developed a standardized insurance verification and authorization process. We would love to tell you more about it. Let us help you avoid costly denials and angry patients through simplifying your processes!
Things You Should Know This Week 10.19.2020
We are grateful for the incredible care
you provide to your patients across the country!
Grace Period Extended for Medicare Accelerated and Advance Payments for COVID-19 Revenue Loss
In March 2020, CMS accelerated Medicare payments to hospitals and advanced payments to physicians and other providers to minimize the effects of revenue shortfalls. Providers that received the advanced and accelerated payments were scheduled to begin repayment of those loans in August 2020, but CMS delayed the start of repayment at that time. In the recent appropriations bill that was signed into law, Congress gave hospitals and other providers that received Medicare accelerated and advance payments one year from when the first loan payment was made to begin making repayments – delaying the start of the repayment period to spring of 2021. Learn more at CMS.
Expansion of Telehealth PHE Codes
CMS recently expanded the list of telehealth services that are available for reimbursement during the COVID-19 pandemic. This list includes nearly 100 CPT codes that are now reimbursable when following the appropriate CMS telehealth guidelines.
News Articles You May Have Missed
NY Times: How Physical Therapy Has Benefits for Back Pain
Chicago Sun Times: Physical therapy can be a key factor in recovery following breast cancer
Don't Be Spooked By 97530!
We understand why therapists are hesitant to bill 97530 - you may be concerned about denials or zero dollar payments.
However, we're here to tell you, don't be spooked by 97530!
There are several questions you should ask yourself when choosing a CPT code. These should all be looked at through the lens of intent of your treatment, progression shown for your patient and as always, compliance and regulatory standards.
By billing the correct contracted codes within the above guidelines, you may also increase your revenue per visit at the same time.
We are currently offering a complimentary chart audits to review your purpose, progression and compliance while also ensuring you are providing correct coding to maximize your reimbursement. Sign Up Here!
Things You Should Know This Week
Additional Stimulus Funds Available
HHS announced $20 billion in new funding for providers on the frontlines of the COVID-19 pandemic. HHS stated that providers who received Provider Relief Fund payments can apply for additional funding. Providers can begin applying for funds TODAY and the application period lasts through November 6th.
Learn more from HHS' full press release.
NCCI Edits Reminder
CMS has reinstated many of the procedure-to-procedure edits, which are more commonly known as the National Correct Coding Initiative Edits (NCCI edits). This rule was actually deleted earlier this year, however, it is effective again NOW for PT, OT and speech outpatient therapy services.
Some popular CPT codes that it impacts are:
Therapeutic activities
Aquatic therapy
Biofeedback codes
Evaluation codes
Manual therapy
The full list of CPT codes is available at CMS.
UHC Cost-Sharing Update
UnitedHealthcare is expanding cost share waivers for their Medicare Advantage and Individual and Group Market health plans for COVID-19 Treatment:
Individual and Group Market health plans: Cost share waivers (copay, coinsurance and deductible) for in-network COVID-19 treatment are extended through Dec. 31, 2020. Out-of-network cost share waivers will end Oct. 22, 2020. Implementation for self-funded customers may vary.
Medicare Advantage: Cost share waivers (copay, coinsurance and deductible) for COVID-19 treatment are extended through Dec. 31, 2020. This applies to in-network and covered out-of-network COVID-19 treatment.
For more details on telehealth billing guidance and provider type eligibility, visit UHC.
Deadline to Submit Comments to CMS on Payment Cuts
The deadline for comments is TODAY to fight the proposed 9% cut in payment for physical therapy services that is scheduled to begin on Jan. 1.
It only takes 60 seconds to submit comments so we encourage you to do so through APTA's link.
Building Success With Today's Coding Changes
Building a strong foundation for your PT practice has never been more important. From your clinicians, to your front office, to your billing team - every piece must work in tandem to deliver each visit successfully. One missing link and everyone's building block contribution to your practice will get lost.
One major piece of this is coding. You therapists need to be billing the correct codes for the services they are delivering and your billing team has to know which modifiers are important to be attached to those codes and how to get them paid.
If you don't have the right builders in place, things are about to get a lot more challenging for your practice. The recent and upcoming changes will have a major impact to your bottom line to the tune of up to $30/visit.
CMS has reinstated many of the procedure-to-procedure edits, which are more commonly known as the National Correct Coding Initiative Edits (NCCI edits).
This rule was actually deleted earlier this year, however, it will now be in effect TODAY - October 1st for PT, OT and speech outpatient therapy services.
Some popular CPT codes that it impacts are:
Therapeutic activities
Aquatic therapy
Biofeedback codes
Evaluation codes
Manual therapy
Just to name a few
Do you think it is time to get an inspection of your "building" to make sure your coding and billing practices are exceeding standards? Contact us, we would love to help!
We are offering a complimentary coding and billing assessment - click here to set one up for your practice.
Falling Into Increased Revenue
On September 21st, Lincoln Reimbursement Solutions CEO, Bryanne Johnson, and President, Danielle Pantalone, held an interactive webinar highlighting what is new in the news, what it means for you, and how you can spend this next season "falling" into increased revenue.
Topics Covered Include:
The CMS Proposed 2021 Physician Fee Schedule
8-9% reduction in payments
How to advocate against these cuts
Outpatient Therapy Modernization and Stabilization Act (HR 7154)
Reprieve from Medicare cuts
Updates to telehealth
Small boots in fee schedule
PPP and Medicare Accelerated payments:
Tips for what you should be doing today to prepare for repayment/forgiveness
Updates to telehealth:
Permanent policy solution proposed
Cost-sharing and how to handle with patients
Updates to the NCCI edits:
Reinstatement of code pair prohibitions effective 10/1
How this impacts commercial payers
You can watch the webinar at this link.
Still have more questions about these topics or something else? Contact us at hello@lincolnrs.com today!
New CPT Code to Cover COVID-19 Related Costs
On September 8th, the American Medical Association released a new CPT code (99072) to report the cost of additional personal protective equipment (PPE), cleaning supplies, and clinician / clinical staff time needed to safely provide in-person services during the public health emergency due to COVID-19.
99072 was created to capture the cost of supplies and activities required to reduce the spread of COVID-19. It can only be used 1x per encounter per day and in non-facility settings.
CMS, state Medicaid plans, and commercial payers have not yet announced whether they will cover this code and if so, what the fee schedule will be. We recommend having your billing team call insurance companies to obtain this information.
Things You Should Know This Week
TAKE ACTION: Planned Medicare Cuts 2021
As we mentioned in a previous email, the current CMS proposed rule has a 9% reduction for physical therapy and occupational therapy payments and an 8% proposed cut to speech therapy payments.
Over the last six months, you have cared for your patients at unprecedented levels while also fighting to keep your businesses intact. Now is absolutely not the time for CMS to cut reimbursement levels especially as we are entering another phase of the pandemic.
It is up to us to be as vocal as possible and tell our Members of Congress why this rule shouldn't take effect!
You don't need to be an APTA member to use this link to send a message to your Congressperson. It will take you less than 5 minutes but can have a huge impact on your bottom line come January 2021.
All comments are due by October 5th. Please encourage your colleagues, friends and family to weigh in on this issue as well.
UPDATES: NCCI Edit
In a reversal of course, CMS has announced that effective October 1, 2020, it will reinstate the previously deleted coding edits for code pairs including:
97530 with 97116
97530 with 97164
97161 with 97140
97162 with 97140
97163 with 97140
99281-99285 with 97161-97168
97110 with 97164
97112 with 97164
97113 with 97164
97116 with 97164
97140 with 97164
97150 with 97110
97150 with 97112
97150 with 97116
97150 with 97164
This is extremely unfortunate given CMS had just agreed to remove the edits in April. The full list of edits can be found on CMS NCCI Edits page.
When is 97164 Appropriate to Bill?
Therapists often get confused between when they should bill a progress note and when they should bill a re-evaluation. However, there are extremely strict guidelines when it comes to using each code.
Re-evaluations are not routine and shouldn’t be billed as such. Progress notes are routine and are completed at every 10th visit or every 30 days (whichever comes first).
According to Medicare, “Routine re-evaluations of expected progression in accordance with the plan of care, either during the episode of care or upon discharge, are not considered to be medically necessary separately billable services.”
When medical necessity is supported, a re-evaluation (97164) is appropriate for:
A patient does not respond as anticipated to the treatment outlined in the current plan of care, and a change to the plan is necessary.
A patient undergoes surgery mid-plan of care.
A former patient returns to therapy after discharge with complaints similar to those you treated previously.
A current patient develops a newly diagnosed, related condition.
A current patient develops a newly diagnosed, unrelated condition.
A patient undergoing therapy treatment demonstrates an unexpected and significant change in status.
It is important to note that 97164 can be billed and bundled with other 97xxx codes with the addition of the 59 modifier to indicate the service is separate and distinct.
Still confused or have additional questions about the use of 97164? Contact LRS at hello@lincolnrs.com and we can help!
3 Essential Billing Benchmarks of a Healthy Practice
It is essential as healthcare practice owners that you are monitoring your billing goals to ensure that your practice is healthy and thriving.
Here are three billing benchmarks that LRS recommends being aware of at all times:
Denial/First Pass Payment Rates
How many denials are you receiving and how many claims are paid on the first try? Many factors go into these metrics including how accurate your insurance verifications are, how clean your claims are, and how timely your claims are submitted. A very efficient practice will have a denial rate under 5% and a first pass claim rate higher than 95%.
Percentage of Receivables over 120 Days
How quickly are you collecting the money you are owed? You should be aiming for less than 10% in this aging bucket. There are always going to be issues with specific claims but a healthy practice has at least 75% of their AR in under 60-days outstanding.
Payer Mix/Expected Revenue per Payer per Visit
Who are your top 5-10 payers? What are they paying you per visit? Your reimbursement rate is only as good as the payer mix of patients that you see.Maybe it is time to try to renegotiate contracts or consider going out-of-network with some insurances. LRS also recommends knowing what you are being paid per CPT code per payer per visit.
These are only a few of the KPI metrics you should be reviewing on a monthly basis. Do you see room for improvement in your practice? Contact us today at inquiries@lincolnrs.com to see how we can help you improve these essential benchmarks.
Thing You Should Know This Week
Proposed 9% Cut to PT and OT and 7% Cut to ST:
The Centers for Medicare and Medicaid Services (CMS) released the 2021 Proposed Rule for services paid under the Medicare Fee Schedule. This includes all outpatient PT, OT, and ST services provided under Part B benefits.
The biggest challenge for our industry that has been looming overhead was the original 8% proposed cut to reimbursement. The 2021 proposed rule has taken this a step further with a proposed 9% payment cut in 2021 to PT and OT services and 7% cut to ST services. This greatly undervalues therapists and the tremendous service that is provided to the Medicare population.
Now is the time to take action and let your voice be heard. All comments to CMS are due by October 5th. We will be in touch in the coming weeks with ways you can easily comment to CMS on this and the other issues in the proposed rule.
Telehealth Coverage Updates
A potential positive proposed 2021 rule is that telehealth coverage could be here to stay! The rule would make permanent telehealth and workforce flexibilities provided during the COVID-19 Public Health Emergency while also improving healthcare for Americans in Rural Areas.
Learn more details of the 2021 Proposed Rule on the CMS Fact Sheet.
Be Prepared!
Due to the Public Health Emergency, CMS could release the final rule as late as December 1 and still have policies effective January 1, 2021. There could be little time to prepare your bottom line for the coming changes if the proposed payment cut takes effect. Contact us to learn more about the changes you can make today to improve your reimbursement.
Credentialing Best Practices
Much like the way the engine is the most necessary part for a car to drive down the street - credentialing is the most necessary piece for your practice to get paid for the claims you submit to insurance. Without effective and efficient credentialing, your practice’s bank account is going to stall shortly after it rolls out of the parking lot. It is that pivotal to your success!
So what can you do to ensure your credentialing is in working order?
1. Ensure accurate effective dates:
Knowing the effective date of a contract or a provider’s participation date is a critical piece of the credentialing process. This will ensure your claims are paid and avoid unnecessary denials.
Do not bill a new payer contract until you have confirmed the effective date. If you bill claims with dates of service prior to receiving your fully executed contract, you will surely receive denials that won’t uphold appeals.
Be sure to inquire with the payer about backdating of effective dates. If you know an effective date will be backdated to today’s date (or potentially earlier), you can treat patients in the meantime and hold the claims while waiting for the credentialing approval.
2. Ensure proper time frame for credentialing:
Familiarize yourself with the time frames it takes to receive approval for credentialing and re-credentialing. These time frames vary widely payer to payer.
Ask for confirmation of receipt when submitting an application. Follow up every 2 days until confirmation is received.
After you’ve received confirmation of receipt, follow up every 2 weeks until approval is received.
Keep a spreadsheet to organize progress, follow up intervals, and responses.
Set reminders to ensure no follow ups are missed!
3. Ensure billing and credentialing departments are communicating:
Your billing and credentialing departments should have a solid process in place for communicating credentialing status’ and how that directly affects the submission of claims.
It’s essential that your credentialing department shares all crucial information, including: pending, approved, and terminated credentialing status’; claims that need to be held and when those claims are okay to be submitted; and contract intricacies to ensure that the EMR and claims reflect the contract details.
Do you think your credentialing could use some fine tuning? Don’t let a bad mechanic operate on your credentialing engine! Contact LRS today to see how we can improve your processes and cash flow!
8 Minute Rule - AMA V. CMS
8 Minute Rule - AMA v. CMS
Unfortunately, very few therapists understand the core differences between billing for insurances that follow AMA guidelines and insurances that follow CMS guidelines. Within your EMR, you should be able to set up and customize the billing and payer settings to ensure you are billing accurately and getting reimbursed properly for the services you have rendered.
Please note: It is important for you or your billing team to verify with each insurance carrier to determine which guidelines they follow.
Here are some side by side examples to ensure understanding. Please see our previous post here if you would like a more detailed breakdown.
Example 1
Example 2
Increasing Your Revenue Per Visit
“Give me six hours to chop down a tree and I will spend the first four hours sharpening the axe. - Abraham Lincoln”
At LRS, we pride ourselves on efficiency and process improvement. Our company is named after Abraham Lincoln - we focus on ways to make your practice more efficient and in turn, collect every penny of what you are owed.
Since we started our company six years ago, we have been sharpening our axes.
Join us on June 23rd at 12:00pm EST to learn three ways physical therapy practices can sharpen their best practices and increase their revenue per visit.
Redundant v. Progressive Coding
Moving from basic to advanced activities - purpose, progression and compliance.
CMS v. AMA 8-Minute Rule
How each work and what they mean for you, your billing and your reimbursement.
59 Modifier Denials and Adjustments
Payers we see this with, adjustments v. denials, and how to approach these.
Join us next Tuesday, June 23rd at 12pm EST to learn more about each of these topics and the steps you can take to increase your revenue per visit immediately!
You’re Invited: Increasing Your Revenue Per Visit
INCREASING YOUR REVENUE PER VISIT
Contract re-negotiation was more than challenging in normal times, let alone now when insurance companies are looking to cut costs even further - but re-negotiating isn't the only way to increase your practice's revenue/visit.
Join Lincoln Reimbursement Solutions CEO, Bryanne Johnson, President, Danielle Pantalone, and DPT Ashley Geer, for an interactive webinar where they discuss how you can increase your revenue through better coding practices, maximizing the 8-minute rule and appealing 59-modifier denials. These are all measures you can take TODAY to improve on your bottom-line!
Things You Should Know This Week
Tricare No Longer Covers TENS Treatment:
Effective June 1, 2020, Tricare will no longer cover TENS treatment for beneficiaries for acute, sub-acute and chronic low back pain. Dry needling also remains a non-covered benefit when it is the sole purpose for the visit.
Telehealth Updates:
Humana will now cover telehealth for outpatient physical, occupational and speech therapy and will follow CMS guidelines and/or state specific guidelines where applicable.
Aetna Extendeds Telehealth Coverage: Due to COVID-19, Aetna has announced that they will cover outpatient physical, occupational, and speech therapy via telehealth until August 4, 2020.
United HealthCare also extended their outpatient physical, occupational and speech therapy coverage for telehealth until September 30, 2020 for their Medicare Advantage plans and until July 24, 2020 for Individual and fully insured Group Market health plans. UHC Community Medicaid plans remain unter state-specific regulations
Paycheck Protection Program Flexibility Act of 2020 (H.R. 7010)
This was signed into law on June 5th. It will:
Allow forgiveness for expenses beyond the 8-week covered period to 24 weeks;
Increase the current limitation on non-payroll expenses (such as rent, utility payments and mortgage interest) for loan forgiveness from 25 to 40 percent (in other words, the eligible recipient is required to use at least 60% of the loan amount for payroll costs, down from 75%);
Extend the program from June 30 to December 31;
Extend loan terms from two to five years;
Ensure access to payroll tax deferment for businesses that take PPP loans.
Thing You Should Know This Week
Medicare Allows Institutional Providers to Bill Telehealth
Medicare FINALLY announced that they will be allowing institutional providers to perform telehealth services. This announcement includes: Rehabilitation Agencies, Skilled Nursing Facilities doing Part B, Comprehensive Outpatient Rehabilitation Facilities, Hospital Outpatient Therapy Departments (including Critical Access Hospitals) and Home Health Agencies providing outpatient therapy in the home.
Denials and Adjustments You Should Be Appealing
Are you missing appealable denials? Anthem BCBS, Aetna and Humana all have been denying providers who bill 97530 as mutually exclusive. Their EOBs sometimes read as a contractual adjustment and not a denial and therefore, you might be missing out on significant reimbursement! Make sure your billing team is reviewing these EOBs thoroughly and are submitting appeals for this issue.
Telehealth Billing Regulations
Has your staff been trained on telehealth billing and current regulations? These rules have changed multiple times over the last few weeks and months. Now is a good time to review with your team on the do’s and dont’s of telehealth compliance. Here are a few great resources:
The LRS Customer Service Difference
6 Ways to Provide Patients with Exceptional Customer Service
At LRS, we pride ourselves on our exceptional customer service. We think of ourselves as an extension of your practice and want your patients to know how much you care about them.
We wanted to share some of our customer service secrets with you to see if there are tips you can implement in your own practice.
Effective Listening: Patients are calling for a reason and they want someone to assist them with solving an issue or to get answers to their questions.When you really listen to patients, you can learn what the patient truly needs assistance with rather than assuming. By doing this, it shows the patient that you truly care about them and their concerns.
Courtesy: Not sure if people get super excited to call their medical office to pay a bill or talk about insurance but at least we can make it as painless as possible! Answering the phone with a greeting and a person smiling through the other end of the phone just sounds warm and comforting rather than “What do you want?” A welcoming greeting to someone is just a better way to start off a conversation. You can also personalize the experience by asking for the patient's name and using it through the entire phone call. Even being polite can go a long way - remember your please and thank yous! Treat patients like your guests.
Efficiency: Gathering information can take some time. Strive to find accurate information in a timely fashion. Following up quickly and having all the information the patient requested makes a patient feel important. Giving a deadline to your patients also helps so they can expect a call back rather than feel forgotten.
Resolving Issues: Take a problem and find a solution! Whether that’s thinking outside the box or asking more questions. We want to explain and communicate to our best ability so that the patient understands what is going on. “I don’t know” will NEVER be in our vocabulary. We make our explanations as simple as possible so that everyone can understand the medical billing world.
One Team, One Dream: We are an extension of your medical office but the patients do not need to know that. We work together as a team so the patient can’t see where the line is between the clinic and the billing department.
Thank You: We cannot thank our patients enough for allowing us to help them with their billing needs, trusting us in helping them find a solution to their concerns, and giving us time out of their busy schedules to talk to us. A simple “thank you!” at the end of a conversation leaves a positive, memorable impression.
These 6 strategies are things that we do every day at Lincoln Reimbursement Solutions that makes us different from the other medical billing companies. We call it the LRS Difference. Our patients are very important to us and we strive to provide the most exceptional customer service! We hope that we can share our exceptional service and our medical billing solutions with you when you join our LRS Family!