HCA240 - Biller Benefits Coordinator Interview PDF

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Biller/Benefits Coordinator Interview

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Biller/Benefits Coordinator Interview MR Grand Canyon University: HCA240 2020

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Understanding the revenue cycle process from beginning to end is extremely important. The process generally includes an inquiry into the health care benefits that are available, submission of any pre-service notifications or authorization and from there, service is rendered and a bill, better known as a claim for services is sent to the health care insurance and once adjudicated, a bill is sent to the patient. I interviewed Nicole Jones, who is the Revenue Cycle Manager for the Professional Healthcare Network, which is a home healthcare agency; which provides a wide range of services from physical therapy (PT), occupational therapy (OT) and skilled nursing. In talking with Ms. Jones, I requested she talk me through their revenue cycle process. Cleverley writes that healthcare firms are for the most part business-oriented organizations, whose survival depends on consistent and recurring flow of funds based on the services they provide to patients, the process of billing and collecting said funds is the revenue cycle (Cleverley, Song, & Cleverley, 2011). The process of health care revenue cycle is one that requires an expertise, so much in fact that many companies exist to provide solely this service to health care practitioners of all types and there are even revenue cycle consultants who will come in and evaluate your current process and help implement changes to improve process and ultimately lead to higher revenue. It is said that time spent on billing, processing claims and other repetitive tasks could contribute to administrative waste within health care systems (Hillman, 2020). Ms. Jones advised that for all patients, benefits are verified prior to rendering service, but because 99% of their services are with HMO policies, this usually includes a referral which causes the benefits to be verified immediately and all patients are notified of their benefits prior to receiving service. Ms. Jones noted post service, her organization is currently averaging

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roughly 20 days to send bills out, which she notes is a huge shortcoming and the main focus of improvement presently. In an effort to expedite the adjudication of claims, the Professional Healthcare Network submits about 90% of claims via electronic submission and 10% via paper and mailed out. Ms. Jones notes “We are trying to switch one central clearinghouse, but certain payers prefer we use their clearinghouse of choice.” I inquired about differences between patients who pay cash, third party insurance and Medicare/Medicaid patients. Ms. Jones noted presently they mainly see patients with HMO policies. She did note that Medicaid and Medicare have several layers of approval that obtain, which helps to ensure timely processing and payment of claims with no patient responsibility. I inquired how healthcare charges and pricing processes differ from other industries. Ms. Jones was quick to note that their charges are episodic, so one visit would likely be billed for PT/OT; which makes them unique from other industries because we currently only accept referrals and do not accept any insurances where we could be considered out of network. This was interpreted as locking down a niche market of sorts. The interpretation provided by Ms. Jones ties in with Health Rev Partners, who are set to disrupt conventional practices by taking on a new modern and consultative approach to revenue cycle management for home health and hospice (Healthcare Executive, 2020). "Not every agency can afford a consultant, but many agencies need help identifying key factors that affect financial performance that go beyond coding and billing processes. With our tech-driven technology platform and expert team, we're able to dig deeper to identify breakdowns in processes and areas for improvement or training," adds Greenlee (Healthcare Executive, 2020).

Biller/Benefits Coordinator Interview Ms. Jones closed out our interview by answering how she felt private and government insurers and payers impact actual reimbursement. “Government payers tend to have more requirements, but the payments tend to be more consistent. For instance, we have several reporting and regulatory requirements we have to meet with our contracts- such as, our passwords have to be a certain length and we have to have so many agencies in one county for one of our Medicaid Plans. Private insurances have less requirements, but payments are not consistent.” It’s clear to see that consistency in reimbursement is the goal for any health care practice or practitioner, but achieve that consistency can and often times is extremely difficult. As soon as a solution is found to circumvent a rule or regulation, the payor often develops another one to quickly replace it and create constant roadblocks to reimbursement.

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Name: NJ Title: Revenue Cycle Manager Organization: Professional Healthcare Network What type of service do you provide to your patients? - We are a home healthcare agency. We provide PT, OT and Skilled Nursing to homebound patients once they are discharged from the hospital. What does your pre-service E&B/PA process look like? If benefits are verified, are they relayed to the patient prior to rendering service? - Benefits are verified prior to service. 99% of our business is HMO, so we usually get a referral, which begins the verification process. The benefits are relayed to the patient prior to service. After service is rendered, how quickly does your team submit the bill for processing/payment? - This is currently weak spot for us. Our average turnaround time for billing out claims is around 20 days. I was brought in to speed this process up. Our goal is to get all claims billed within 7 days of service. Do you submit claims electronically or via paper? If done electronically, what clearing house do you utilize? - Our claims are sent about 90% electronic and 10% paper. We are trying to get our last line of business electronic, but we are running into issues with the clearinghouse- which we are trying to resolve. We currently use several clearinghouses (Optum, Availity, Doodad, and smartdata) We are trying to switch one central clearinghouse, but certain payers prefer we use their clearinghouse of choice. Does your team follow up on claims? How often? Is follow up via online pull, IVR, or phone calls with live person? - This is another weak spot for us. Currently there is virtually no follow up. We have a lot of outstanding A/R. I’m currently working on a process that will involve online pulls and phone calls. Do you appeal on behalf of your patients? - We do not at this time. There is no out of pocket to the patient. We are moving into the PPO space and there will be a patient cost share Regardless of filing or appeal or not, how soon do you bill patients for their financial responsibility? - We currently only service HMO patients so there is no out of pocket cost to our members, but once we service PPO clients we aren’t sure how the billing of patients will look yet. Do you balance bill out of network patients for the difference? - We currently do no accept out of network patients

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If patient responsibility is not satisfied, do you utilize patient collections? - N/A Do you offer a financial patient assistance program? - N/A What are the differences between a patient paying with case, third party insurance and/or Medicare/Medicaid? - Medicaid and Medicare have several layers of approval that we need- authorization, EVV (Electronic visit verification) How do you see healthcare charges and pricing processes different from other industries? - Our charges are episodic, so one visit may bill for PT/OT. We are unique from other industries because we currently only accept referrals and do not accept any insurances where we could be considered out of network. In your opinion, how do private and government insurers and payers impact actual reimbursement? - Government payers tend to have more requirements, but the payments tend to be more consistent. For instance, we have several reporting and regulatory requirements we have to meet with our contracts- such as, our passwords have to be a certain length and we have to have so many agencies in one county for one of our Medicaid Plans. Private insurances have less requirements, but payments are not consistent.

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Cleverley, W. O., Song, P. H., & Cleverley, J. O. (2011). Billing and Coding in Health Services. In Grand Canyon University (Ed.), Essentials of health care finance (7th ed.). Sudbury, MA: Jones & Bartlett. Retrieved from https://viewer.gcu.edu/BDGBHD Healthcare Executive Launches Home Health & Hospice Revenue Cycle Management Company. (2020). PR Newswire. Retrieved from https://go-galecom.lopes.idm.oclc.org/ps/i.do?p=AONE&u=canyonuniv&id=GALE %7CA613515183&v=2.1&it=r&sid=ebsco Hillman, Dan. 2020. “The Role of Intelligent Automation in Reducing Waste and Improving Efficiency in the Revenue Cycle: A Portion of the Wasteful Spending in Healthcare Can Be Curbed by Automating.” Healthcare Financial Management. https://search-ebscohostcom.lopes.idm.oclc.org/login.aspx? direct=true&db=edsgao&AN=edsgcl.615910747&site=eds-live&scope=site....