Medical rehab billing may be the exclusive source of revenue for rehabilitation centers, but it is also an important part of billing and coding for physical therapy groups, physician groups with multiple specialties, individual and group practices and hospitals.
The challenges faced by all medical organizations apply to rehab billing, but there are some situations that are especially likely to be relevant concerns. Physical therapists and occupational therapists alike struggle with getting paid properly, and despite updates and changes being made to regulations and billing codes, the overall process isn’t getting much easier.
The Effects of COVID Continue to Have an Impact
Rather than having found a cure for COVID-19 by 2021 as we had hoped, we are going into the new year with the number of new cases continuing to rise. After things had seemed to settle down over the summer, new cases started spiking in larger cities.
Then the Thanksgiving holiday, the largest travel time of the year, arrived and many people who had been staying local since the beginning of the coronavirus lockdowns visited family in other states. Maybe the stable numbers being reported for a while had given us a false sense of security or perhaps people had just waited as long as they could stand without seeing those that they love, but the travel and group gatherings led to the virus making its way into new circles.
Regardless of the reason behind the spread, however, until the new vaccines are broadly distributed and proven effective, COVID-19 patients will require rehab services. From a business perspective, COVID patients generate revenue like any others, though there are likely to be more changes to the billing codes and regulations than normal and the state of emergency that was declared due to the spread of the novel coronavirus means that changes happen much faster than usual.
Providers are expected to keep up with the changes and will lose revenue if regulations change and their billing practices lag behind. Outsourcing rehab billing to a professional billing company can be especially beneficial under these conditions.
As healthcare providers, therapists need to be able to focus on patient care, not administrative duties—and no one providing medical services in this economy can afford to lose revenue to errors made when filling out claims or not having enough time to follow up on submissions that are rejected or denied.
Surprise Medical Bills Continue to Be an Issue
There has always been a problem with insurance and government payers omitting some treatments from what they will cover, and patients have never been happy to receive an unexpected bill. The issue got widespread attention in 2020 because people knew that insurers had been instructed by the government to cover the costs of COVID treatment, so they did not expect to incur high bills.
Because the viral infection could become life-threatening very quickly and treatment facilities were limited, many patients were transported by ambulance and even air ambulance, which has a high cost. Transportation is not included in the treatment cost, so many patients received very high unexpected bills for that.
Surgical assistants and physical therapists can also be the source of surprise medical bills when they provide services at a hospital or other practice but they are out of network for the insurer that the physician is billing. Patients generally have no control over who provides services in the hospital, so are justifiably upset to find out that even though they made sure the hospital and doctor are covered by their insurance, other services are not.
There is no easy answer in sight. Two senators have come up with a bill that is supposed to solve the problem, but it does so by allowing payers to decide how much they will pay for anything, which medical trade organizations claim will drive reimbursements down and result in fewer providers and facilities being available.
Expect to Provide Documentation for Everything
In July of 2020, the Department of Justice settled rehab billing fraud allegations involving a management company and 27 affiliated skilled nursing facilities for $16.7 million. The corporation was accused of pressuring therapists to hit targets for billable rehab minutes that fell into the “Ultra High” category of the Resource Utilization Group (RUG) payment system, which, of course, bill at a higher rate.
The RUG system has been replaced with the Patient-Driven Payment Model (PDPM), but the application of the new system will result in some close inspection to make sure it is not being abused and skilled nursing facilities are not being overpaid.
Our success at Medcare is the result of nearly a decade of medical billing and revenue cycle management experience. We work with our clients to ensure that they get the maximum reimbursement possible. Our transparent reporting process lets you keep track of your KPIs at every stage of the revenue cycle. Call us today at 800-640-6409 to find out how you can be free of the complexities of rehab billing and have a more solvent practice.
Avoid These Common Substance Abuses & Rehab Billing Mistakes
Treatment for substance abuse and rehab has not always been covered by insurance. This addition has proven beneficial for patients and their communities. However, the fact that these treatments can be billed does not mean that they will be paid.
Whether a facility is billing a private insurer or government payer, such as Medicaid, getting paid requires filing a claim just like it does for any medical procedure. Any error on that claim form or even the tiniest piece of missing information will result in the provider being denied payment.
Errors such as an incorrect date or transposed digits can occur in all kinds of medical billing, and claims should be carefully reviewed before submission to ensure that no careless mistakes will result in the claim being denied or rejected. There are also aspects of medical coding and billing that are unique to substance abuse and rehab, which make it important to have expert billers and coders who are experienced with this particular field.
Pay-to-Patient Checks Are an Issue
In some cases, the insurer will issue the payment for services to the patient instead of sending reimbursement directly to the provider. This often results in the provider not receiving their reimbursement.
A very important aspect of managing this kind of problem is communication with the patient up front. They must sign an agreement before receiving treatment promising to use any money received from their insurer to pay the charges made by the facility. It is important for the provider’s billing staff to know which insurance companies make payments directly to clients so that they can make a point of speaking to the patient and getting their agreement that the reimbursement payment must be given to the facility.
Fortunately, it is becoming less common for the payment to be sent to the patient in these cases. Being handed a check for a large sum of money can easily be the undoing of an addict fresh out of treatment. It has happened far too many times that not only does the treatment center not get paid, but the patient uses the money for drugs and ends up right back in addiction. The practice of sending insurance payments directly to people recovering from addiction has been outlawed in 27 states, which is good for patients and providers alike.
Billing the Wrong Insurer Results in Rejected Claims
While it may be obvious that you must bill the right insurance company, the identity of the company isn’t always as distinct as you might think.
Sometimes a business acquires another company and keeps it intact as a separate operation under the corporate umbrella, with a suffix or slightly different name. Insurers have also created subsidiary companies to meet the requirements of different states under the Affordable Care Act.
For example, Blue Cross Blue Shield has business entities specifically for providing coverage in Florida and if a biller sends the claim to a different Blue Cross Blue Shield operation, it will be rejected because the patient’s ID number will not show up in their records.
Billers must make sure to match the exact name of the insurer to the correct contact information for submitting claims.
Procedure Codes Must Match Diagnosis Codes
Each diagnosis has approved procedures associated with it and if the treatment is given without the correct diagnosis code being used, the claim will be denied. The reason for this is that the insurer will not consider it “medically necessary.” Coders need to be aware that each diagnosis has one or more accepted treatments and should know what they are. If there is not a good match, the physician should be asked for clarification before submitting the claim.
Consultations Between the Treating Physician and a Specialist Consultant Are Billable
There is a category of CPT codes called “Inter-professional Telephone/ Internet/Electronic Health Record Consultation” that includes billing for instances in which a treating physician or other qualified health care professional seeks treatment advice from another physician who has specialty expertise. The consultant can speak with the treating physician without seeing the patient face to face and it is still billable.
Failure to Follow Up on Claims Causes Lost Revenue
Up to 25% of potential income is being lost by substance abuse and rehab facilities because they don’t have effective (or any) processes in place to collect on their bills. There are many reasons that claims are rejected and denied. Some of them have been discussed here, but there are many more. Most are easily avoidable, but the medical coding system is complex and billing can be challenging.
When a claim comes back unpaid, the insurer/payer must provide a reason, but these can be pretty vague. An experienced biller needs to review the claim, find the cause of the problem and correct the information or provide the necessary explanation or documentation to get the claim paid. It is very difficult for in-house billers to keep up with ongoing billing and still have time to examine unpaid claims, so millions of dollars are lost every year.
Medcare MSO is a medical revenue cycle management company with a long track record of streamlining medical billing processes and increasing revenue for our clients. Call us at 1-800-640-6409 today to find out how we can help make your treatment or rehab facility more financially sustainable.