Assuring that the correct provider charges are billed can be extremely challenging - despite last year’s updates to the Evaluation and Management coding criteria. Recent studies indicate that the perceived benefits of these new guidelines are yet to be realized. Creating workflow-based solutions to assist has proven especially difficult for information technology professionals. What are some of the complexities to consider? How can integrated solutions help support the varying needs for physician billing? Consider these provider billing challenges and how your healthcare organization can design and optimize systems to maintain revenue streams.
The variability of hospital billing structures
The complexity begins with the number of different contractual relationships healthcare organizations can have with their provider community.
- Are they employed providers? Does the healthcare organization process the billing such as facility charges, supply charges, professional fees and other fees for the provider? Or is the organization merely paying the provider a salary?
- Are they contracted with a company that employs the provider and bills their facility for technical fees, procedural and supply fees but the other entity bills for the professional fees?
- Is there a hybrid billing model that includes some of the above? Perhaps there is a contractual difference by contract, insurance carrier or other entity that dictates who bills for what and how?
These relationships and scenarios within hospitals and/or healthcare organizations can create a multitude of potential billing, coding and even documentation needs. The variety of scenarios within a single organization can require extremely complex workflows for accurate billing.
Add the varying types of codes that could be used for these services, E/M level codes, CPT procedural codes, HCPCS codes and you’ve added even more complexity to the matrix. Hospital charge capture, coding and claims generation commonly use encoders with inpatient/outpatient groupers in order to assist with encounter-based coding. Groupers do not normally include a physician coding module – that is usually an “add-on” module if it is even available from the encoder vendor. While many companies offer computer-assisted coding in the acute space or computer-assisted documentation that integrates with the coding processes, these technologies are still relatively new. Many of these solutions do not address the provider side, don’t launch at the right place within the provider documentation workflow or are cost prohibitive.
Different criteria for provider billing
Professional services provided to a patient as part of an inpatient stay can use different guidelines for determining the correct evaluation and management code than if that patient was seen in a hospital-based clinic, the emergency department and/or a provider’s office.
In addition, professional billing is submitted on different claim types and requires different claim field values than hospital and hospital clinic/department billing. These require additional maintenance and development in the chargemaster and claims modules.
Workflow examples: Contract changes
Here are several examples of the variation that can exist in who bills for provider services.
- Billing accuracy. If an organization originally bills for Emergency Department (ED) professional fees, but then later contracts to have this done by an outside entity, then claims and workflows must be modified to prevent “double billing” by the healthcare system and the outsourced group.
Technology impact: When physician billing is heavily influenced by contracts with vendors or external companies, then those contracting decisions directly impact information technology staff. Contracting changes often mean system changes are needed to block and/or add charges for accurate billing.
- User provisioning. For example, a general practitioner could be billable by a hospital’s physician billing group when seeing patients in a clinic setting. However, that same provider might not be billable if they are moonlighting in the hospital as a hospitalist if that pro fee billing is outsourced to an external billing company.
Technology impact: This use case requires flexibility both in setting up providers who are provisioned within a single healthcare entity to bill and not bill. Also, consideration will need to be given when setting up patient accounting and billing claims systems to accurately determine what services are billable versus non-billable per contract(s).
Although provider billing volume is often high, this workflow area is often overlooked because provider billing revenue is lower when compared to inpatient stays, surgery, or imaging. Reporting can be challenging, too, since provider needs and contracts vary, and healthcare entities may be required to report to both outside organizations and internally to the practice management group. As a result of these competing criteria, hospital information systems (HIS) have responded with a renewed focus on physician billing.
- MEDITECH Ambulatory. The Ambulatory (AMB) module allows providers to have a shared clinic (AMB) and hospital (acute) record in an integrated system. It has a built-in Coding Visit Workflow (CVW) designed to support physician coding and billing.
Provider documentation templates and protocols can assist in capturing complete documentation based on condition and/or reason for visit with fewer clicks as well as integrate with ordering to improve the provider workflow. The integrated coding functionality helps the provider determine the best code for the visit provided and communicate easily with the coding staff.
- EpiCare Ambulatory. Epic has a similar integrated solution called EpiCare Ambulatory, which, like MEDITECH AMB, features integrated orders, e-prescribing, tracking of office procedures, support of telemedicine visits and other patient communications and interactions.
Customizations within Epic streamline workflows so providers can document quickly with fewer clicks which helps them work more efficiently. Clinical documentation and charges flow through the system to the claim, and collaboration with Epic analysts on system optimization can help prevent denials and result in a cleaner claim. In addition, coding and billing education for newly onboarded providers can help foster a seamless and accurate billing process.
Technology impact: Regardless of the electronic health record (EHR) solution, healthcare organizations who perform professional billing have the ability to develop workflow-driven, integrated solutions to support these varying needs for physician billing.
Working together for system and revenue stream optimization
In summary, as business and IT operations collaborate on how to solve billing challenges and address variances in provider billing, here are four key principles to focus on:
- Patient-centric solutions are coupled with information security – this is foundational regardless of EHR platform.
- Physician-centric solutions give providers the ability to access, review, and document easily in both the ambulatory and facility/acute settings.
- Flexible systems should support all provider coding and billing guidelines.
- User provisioning/billing options for employed versus community providers should easily flex with contracting obligations.
By understanding the differences between the provider and hospital coding, billing and IT needs, healthcare organizations can better plan and coordinate across departments to meet these variances. Better planning and coordination can lead to greater optimization for systems and revenue streams.
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