Revenue Cycle Decoded

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In this episode, I discuss four processes that can break down in the front end of the revenue cycle that will cost you time and money.

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Hi, and welcome back to Revenue Cycle Decoded where we are making sense of revenue cycle for medical practice managers. Today, I’m talking about meeting medical necessity. So, what exactly is medical necessity and why does it matter when you are coding your claims? Well, our payers consider whether a treatment or service we provide is medically necessary for the patient’s condition on the date of service, and if so, the claim will be paid, assuming we submit a clean claim and everything else on the claim is correct, and the treatment is medically necessary to care for our patient on that date of service. In that case, we would meet medical necessity according to payer guidelines. However, payers also may decide that some treatments are not medically necessary for that patient on that date of service for a variety of reasons, and we’ll look at a couple of examples here in a minute. But for example, if a treatment is considered to be investigational or experimental, in that case, the payer likely will not consider the treatment to be medically necessary and they may not pay you if you perform that treatment for your patient. Another reason would be if we performed a treatment that doesn’t match up with what the patient’s condition is on that date of service. So how does a payer tell if a treatment or a service that we provided matches up with the patient’s condition to determine if it’s medically necessary. Well, the way is ICD-10 codes and CPT or HCPCS codes. As we know, computers understand computer language, they understand numbers. We submit these codes on our claims. Our ICD-10 codes tell the payer why we did what we did on the date of service. This is the diagnosis, or the diagnoses, of the patient’s condition or conditions. And then, the CPT or HCPCS code(s) tells the payer what we did. And so, if what we did matches up with why we did it (the ICD-10 code), that all links up and makes sense, then it meets medical necessity. However, if it doesn’t, then it wouldn’t. So, let’s look at an example here. In the first case, we have a patient who has presented to us with a displaced comminuted fracture of the left tibia. Now, one of the treatments for this, in addition to perhaps surgery, would be placement of a long leg cast. According to best practices, this would be one of the treatments provided for this condition. So, in this case, the ICD-10 code would match up with the CPT code that tells the payer what treatment we provided for the patient’s fracture. That way, the payer sees that this treatment is medically necessary, and they pay for the treatment. But if we submit on our claim an ICD-10 code, a diagnosis of why we did something, and a CPT or HCPCS code, the “what” we did, and it doesn’t match up or link up in the payer’s system, in this case, it’s going to not meet medical necessity and it’s going to get denied. So, what’s an example of this? In this case, we have a patient who has presented with a sprain of the left ankle, and we’ve applied a short leg cast. Well, that wouldn’t usually be the treatment for a sprain, a simple sprain of the ankle, where the physician may recommend wrapping the ankle or putting ice on it, but we generally are not going to cast a sprained ankle. And so, those codes don’t match up – they don’t make sense to go together. And so, your payer system is going to recognize that and deny that claim as not medically necessary if it was submitted this way. Now, what does the payer say? Well, we are going to have to check the payer policy to see what they consider to be medically necessary for a specific condition. And they may not have a policy for everything, but for the things that you are doing in your office, you certainly should be aware if they do have policies. For Medicare, this will be your Local Coverage Determinations or your National Coverage Determinations and also your Local Coverage Articles. Since 2019, Medicare has been moving the ICD-10 codes and the CPT codes into the Local Coverage Articles that often accompany a Local Coverage Determination, so you would want to check both to see which treatments and services are considered medically necessary for a patient’s condition. For a commercial payer policy, you may need to go out to their website and look to see if they have a policy for the particular treatment that you want to perform. And I just want to make a quick mention of unspecified codes. We know with ICD-10, we should be coding to the highest degree of specificity. If we submit so-called unspecified codes on the claim, they may not meet medical necessity in every case. You should be aware of how the payer views submission of unspecified codes on the claim and whether they will pay for those codes or not. Sometimes, it’s simply educating your physicians and providers to document in order to choose the most specific, most granular ICD-10 codes. So that is medical necessity in a nutshell. I hope this has been helpful to you. If it is, please like, subscribe, follow. I’ll be creating many more videos to help you make sense and demystify revenue cycle. I look forward to talking to you soon – have a great day! Follow us on social media: YouTube: https://www.youtube.com/channel/UCg2DNvyiGvOhX2Ucv287xOQ Facebook: https://www.facebook.com/groups/revenuecycledecoded LinkedIn: https://www.linkedin.com/groups/14020141/ Twitter: https://twitter.com/RevCycleDecoded

In the second episode of this multiple part series, we dive into the details of the Interim Final Rule Part 1 for the No Surprises Act. Learn the rules and requirements around the No Surprises Act and how it impacts emergency services, including balance billing, out-of-network coverage, and which services are covered in this episode of Revenue Cycle Decoded where we crack the code on revenue cycle topics for medical practice managers.

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Transcript:

Hello, and welcome to Revenue Cycle Decoded where we are cracking the code on revenue cycle topics for medical practice managers.  In this episode, we are going to continue our discussion of the No Surprises Act, in particular, the Interim Final Rule Part 1 as it applies to emergency services.  

 So, in our previous episode we provided background on the No Surprises Act. This final rule became effective January 1 of 2022, and so it's very important that you understand what the requirements are and how they impact you, and what you need to do to be compliant. So let's dive into how this Act applies for emergency services. 

 The No Surprises Act protects against balance billing and out-of-network cost-sharing with respect to emergency services, non-emergency services provided by non-participating providers at certain participating healthcare facilities and air ambulance services furnished by non-participating providers.  Today, we're specifically going to focus on emergency services. 

 So, the No Surprises Act applies to group health plans and to health insurance issuers offering group or health insurance coverage and to carriers in the Federal Employee Health Benefits program. Specifically for emergency services, the Final Rules applies if a group health plan or a health insurance issuer offering group or individual health insurance coverage provides or covers any benefits with respect to services in an emergency department of a hospital or with respect to emergency services in a freestanding emergency department.  In this case, the plan or the health insurance issuer must cover emergency services and cannot require prior authorization for emergency services including out-of-network services, and without regard to whether or not the provider is a participating provider. Emergency services must be provided without regard to any other term or condition of the plan other than the exclusion or coordination of benefits, an affiliation, or waiting period as permitted under the Code, ERISA, or the Public Health Services Act, or applicable cost-sharing requirements.  The plan cannot impose administrative requirements or limitations on coverage for emergency services received from non-participating providers or facilities that are more restrictive than those applied to participating providers and facilities. And it must comply with the Act's requirements for cost-sharing, payment amounts, and processes for resolving billing disputes.  We'll talk about those requirements in a future episode.  

 The No Surprises Act limits cost-sharing for out-of-network services, including emergency services and air ambulance services, to the in-network levels that a patient would be expected to pay, and that cost sharing is going to count toward the patient's in-network deductibles and out-of-pocket maximum.  The facility or provider is prohibited from balance billing the patient for any out-of-network amounts over and above the patient's in-network cost sharing responsibility.  

 According to the Final Rule, emergency services include an appropriate medical screening exam, including any appropriate ancillary services provided by the facility or provider to evaluate if an emergency condition exists. It also includes medical exam and treatment to stabilize the patient regardless of the department of the hospital where that further medical exam and treatment is furnished. In other words, the Final Rule includes pre-stabilization services provided after the patient is moved out of the ER and admitted to a hospital. 

 The Final Rule is also clear that emergency services provided at an independent freestanding emergency department are also included in patient protections. And the Final Rule categorizes any healthcare facility that is geographically hospital and licensed by the state to provide emergency separate and distinct from a services as an independent freestanding emergency department, even if it isn't licensed specifically as an independent freestanding emergency department. In addition, depending on your state law, if urgent care centers in your state are permitted to provide emergency services, they would also fall under the Rule. If they're not licensed by the state to provide emergency services, then in that case, those urgent care centers would not be included.  So, what is important here is whether or not your state law licenses urgent care centers to provide emergency services. 

 Now, order the Final Rule, post-stabilization services are covered as emergency services unless four requirements are met.  

 The first is that the patient is able to travel using non-medical or non-emergency transportation. The second is that the patient receives notice and is able to consent and the patient must be in a condition to receive notification and provide informed consent in order to be transferred to a participating facility for post-stabilization services.  And, finally, any state law requirements must also be met. 

 So let's talk for a minute about the travel requirement.  In this case, the attending emergency room physician or the treating healthcare provider must determine if the patient is able to travel using non-medical transportation or non-emergency medical transportation to an available participating provider or facility located within a reasonable travel distance.  And, they have to take into consideration the patient's medical condition.  Really, this requirement is intended to address situations where the patient has received emergency services far from a geographic region where any participating providers or facilities are located.  And it would also address situations where a patient in an underserved and geographically isolated community or those with social risk factors related to income and transportation may face additional barriers in obtaining post-stabilization services without some disruption in care.  For example, if a patient is not able to afford a cab to another facility or doesn't own a vehicle or have someone who could transport them to a participating facility.  In other words, the Final Rule is trying to prevent patients in these situations from having unreasonable travel burdens placed upon them to obtain post-stabilization services at a participating facility or from a participating provider.  Now the Final Rule does not define reasonable travel distances, and in fact, has requested comment on what would be a reasonable travel distance and what other factors there might be that could add to an unreasonable travel burden. Now, if the patient does require medical transport to travel, then the surprise billing protections do apply.  

 So, now let's turn to the second requirement for post-stabilization services, and that is notice and consent. In order for the patient to be transferred to a participating facility or provider for post-stabilization services, notice and consent has to be provided.  And in this case, the emergency room physician or treating healthcare professional must take into consideration the state of mind state of the patient, as well as the effect of any alcohol and the emotional or drug use, including medication that may have been administered while the patient was in the emergency department.  The treating provider or physician must also consider pain as a factor, and whether or not the patient is in the emergency department for a mental or behavioral health episode.  He must also take into consideration any substance abuse impairment, or impairment due to the patient's condition, the reason why the patient presented to the emergency department or any conditions that may have arisen while the patient was there.  But in addition to these factors, the physician must also consider cultural and contextual factors, and those could include a lack of trust due to historical inequities or misinformation regarding consent process or barriers to comprehension of the information in the notice and consent such as accessibility, language or literacy. In addition, the emergency room physician or healthcare provider must make sure that the patient’s civil rights are protected.  The consent cannot be obtained if the patient is subject to undue influence, fraud, or duress, for example, being threatened with restraint.  There must be a reasonable option for post stabilization services, transport, and service provider or facility.  

 And finally, any state requirements must be met.  Some state requirements may be more restrictive than the No Surprises Act requirements and so, if that is the case, those requirements have to be met in order to meet the standard. In other words, the Final Rule anticipates that post-stabilization notification and consent procedures should generally only be applied in limited circumstances, for example, where an individual knowingly and purposefully seeks care from a nonparticipating provider or facility because they prefer that provider or that facility even though it is nonparticipating with their network. 

 Now, the Final rule uses the standard of a prudent layperson when deciding if the patient has an emergency medical condition.  Essentially if the patient has acute symptoms of sufficient severity including severe pain that a prudent layperson with average knowledge of health and average knowledge of medicine could reasonably expect that a lack of medical attention could result in putting their health in serious jeopardy or serious impairment of dysfunction, and this does include mental health conditions and substance abuse disorders.  

 The Final Rule discusses that some plans and health insurance issuers have made a practice of denying claims for emergency services based on the final diagnosis codes.  And some plans and issuers actually auto-deny all claims for emergency services and then the provider or the facility has to appeal and after the appeal is received, then the plan will apply the prudent layperson standard upon reviewing documentation as part of a complete consideration of the claim.  Instead, a denial in whole or in part must be based on a determination that the prudent layperson standard has been met based on all pertinent documentation and it must be focused on presenting symptoms, not solely on the final diagnosis. 

 In addition, the plan cannot impose a time limit between the onset of symptoms and presentation at the emergency room or restrict coverage because the patient did not experience a sudden onset of symptoms.  And if the plan or issuer provides coverage for any emergency services at all, it cannot deny coverage based on a general plan exclusion that would apply to items or services other than emergency room services, for example, dependent maternity care.

 If this episode has been helpful to you, please like and subscribe.  Our next episode will continue our discussion of the No Surprises Act Interim Final Rule Part One, specifically non-emergency services by non-participating providers at participating healthcare facilities. In the meantime, please visit us at Revenue Cycle Decoded dot com where we are cracking the code on revenue cycle topics for medical practice managers.  Also see the links below in our description to join us on Facebook, LinkedIn, or follow us on Twitter.  Thank you for watching.  We'll see you next time. 

Did the No Surprises Act come as a surprise to you in 2022? If so, we've got all the details you need to know. This first episode will provide the background to the No Surprises Act, including why it was enacted.

Transcript:
Hello, and welcome to Revenue Cycle Decoded where we are cracking the code on revenue cycle topics.

Today, we're going to talk about the No Surprises Act, and if you have been in healthcare for any length of time, you have probably been hearing about the No Surprises Act. It's no surprise because it is a big deal. Now if you're still asking yourself "what is the No Surprises Act," it's time to learn because this Act actually went into effect on January 1, 2022 - that's this year! So, let's get started talking about the background and then in future videos we'll dive deep into the details of the Final Rules so you'll understand what's required and what you need to do to be in compliance.

Now, group health plans and insurers contract with providers and facilities to provide services to the plan members and those providers and facilities are considered to be in-network, or participating, because they agree by contract to accept a certain amount for their services. There are also nonparticipating providers. These providers are not contracted with the plan and so they can charge higher amounts than the contracted rates that plans have negotiated with participating providers and facilities. These providers are out of network.

So, what happens if a patient receives care from a nonparticipating provider even if the patient was at a participating facility and particularly if the patient had no opportunity to choose the provider, for example, in surgery from an anesthesiologist? Well, in this case, the plan could decline to pay all together or the plan could pay an amount less than the bill charges and require greater cost sharing than if the patient had received to care from an in-network provider. In fact, sometimes the costs paid for that out of network provider wouldn't even count towards the patient's deductible or out of pocket maximums. So, in this case, the patient may get a surprise medical bill and these bills could be quite shocking and, in some cases, outrageous.

Balance billing is equal to the provider's billed charges minus the amount that was paid by the plan and the amount collected from the patient's cost-sharing portion. Now, this is perfectly legitimate. For example, if you work for a primary care physician and you bill your patient's plan, there may be a cost-sharing portion, the patient's coinsurance, left over after the plan pays its part and you would bill the patient for the difference.

A surprise medical bill happens when the patient receives an unexpected bill from the health care provider or facility that occurs when a patient receives medical services from a provider or facility that, usually unknown to the patient, is a nonparticipating provider or facility with respect to the individual's coverage. This could happen if the patient received care at a participating or in-network emergency room but was treated by an emergency room physician who is out of network with the patient's plan. It can also happen if the patient is in surgery or receives other services at in network facility and receives care from a provider who is not in network such as an anesthesiologist or a radiologist reading x-rays; or if the patient receives care from an air ambulance company that is nonparticipating with the patient's plan. In all of these situations, the patient had little or no opportunity to choose an in-network provider but was stuck with the costs from receiving services from the out of network provider.

Some of the consequences of these surprise medical bills are devastating. For example, it raises healthcare costs for everybody, but it also exposes patients to significant financial risk. It leads to confusion about medical bills. Patients can certainly be confused when they're receiving a bill from an out of network provider and not understanding why they weren't billed at in-network rates, especially if they went to an in-network facility. Surprise medical bills can also lead to medical debt and even medical bankruptcy and create significant financial hardship, especially in communities exposed to poverty and other social risk factors.

Before the No Surprises Act, there were some patient protections put into place, for example, the Public Health Services Act required that group health plans or health insurance issuers offering group or individual Health Insurance coverage had to cover emergency services without requiring prior authorization and without regard to whether the Health Care provider was in-network and they can't impose any administrative requirements or limitations on benefits for out of network emergency services. In addition, they were required to pay a reasonable amount quote unquote before a patient became responsible for balance billing. However, this Act did not prohibit balance billing and it only applied to emergency services. And let's just say those reasonable surprise bills -- well, from a patient perspective, they weren't so reasonable.

Now, many states have also enacted surprise medical billing rules, and in fact, right now over 50% of the states have some protections in place to protect patients from surprise medical bills but the laws vary dramatically. Some states offer very little protection, while other states offer comprehensive protection, with a lot of states somewhere in between, and this patchwork of consumer protections is limited in its ability to address surprise medical bills from out of state providers and typically only applies in individual and group Health Insurance coverage, not self-insured group health plans sponsored by private employers.

Enter The No Surprises Act. Congress recognized that this was a problem for patients and for healthcare costs overall and so The No Surprises Act was put into place to protect participants, beneficiaries, and enrollees in group health plans and group and individual Health Insurance coverage from surprise medical bills when they receive emergency services, nonemergency services from nonparticipating providers at participating facilities, and air ambulance services from nonparticipating providers under certain circumstances.

Now looking at this list, you may think this doesn't apply to you but wait and see as we dive down into the final rules and you'll find out that, in some cases, yes, it does. In our next video, we are going to dive deep into the No Surprises Act Final Rule Part One. We'll give you all of the details so that you can understand what's required and what you need to do to be compliant.

Be sure and visit us at RevenueCycleDecoded.com where we are cracking the code on revenue cycle topics and be sure to like and subscribe to our channel. Thanks for watching! See you next time!