Category: Clinics

Medicare Rule Regarding Colonoscopies

Posted on by Melissa Lehrer

June 6, 2022

Melissa Lehrer,
CCS, CPC, ROCC,
CCVTC, CIRCC,
AHIMA Approved Trainer
Director of Health Information Management
Director Business Office Services

ParaRev has received several questions regarding coding for colonoscopies. The following Q&A will help provide clarity on the use of modifiers, E/M coding and medical necessity.

Q

We have been working with our coders to better help them understand modifiers XS and XU. When reporting two or more diagnostic colonoscopy codes, is it appropriate to append modifier XS (separate structure), or should we report modifier XU (unusual, non-overlapping service)? For example, we need to append a modifier to report 45380 with 45385 to resolve a CCI edit.

A

The modifier assignment will be dependent on the site of the polyp being removed. If all polyps removed are in the large intestine and each removed by a different method (i.e., cold biopsy, hot biopsy, snare), append modifier XU. The large intestine starts at the sigmoid colon and ends at the cecum.

This is considered one anatomic site.

illustration of acolon with a scope inside

Consider these two scenarios.
Scenario 1:
The patient presents for a colonoscopy. The scope is advanced to the cecum. During the exam two polyps are identified. The first polyp is identified in the descending colon and removed by cold biopsy. The second polyp is identified in the transverse colon and removed by hot biopsy.

In this scenario, report 45384 for the hot biopsy of polyp in the transverse colon and 45380 for the cold biopsy removal of a polyp in the descending colon. Append modifier XU to 45380 for overlapping services. Although the polyps are identified at different areas of the large intestine, they were in the same anatomic site. The services are considered overlapping since the polyps were removed in different methods (i.e., cold biopsy and hot biopsy).

Scenario 2:
The patient presents for a colonoscopy. The scope is advanced to the cecum. During the exam two polyps are identified. The first polyp is identified in the rectum and removed by cold biopsy. The second polyp is identified in the transverse colon and removed by hot biopsy.

In this scenario, report 45384 for the hot biopsy of polyp in the transverse colon and 45380 for the cold biopsy removal of a polyp in the rectum. Append modifier XS to 45380 for separate anatomic site. One polyp was identified in the large intestine and the other polyp was in the rectum. Since the rectum is a different anatomic site from the large intestine, XS is appropriate.

Q

We have been holding bills at our Rural Health Clinic for pre-operative clearance visits for Medicare patients scheduled for a colonoscopy. I have been asked to investigate whether these encounters are billable. We have heard that E/Ms “before/prior to” a screening C-scope were not to be billed. However, for the 16 years I have been in clinic billing we have always billed them if they weren’t the “day before or day of” of procedure, as those would get bundled. We’ve gotten paid just fine and in all those years to my knowledge, none of our MC audits resulted in any take backs or fines regarding our billing them.

We researched coding forums on-line as well, and any data I could find from or regarding MC and screening C-scopes and opinion, is divided. Many stated that the “before/prior to” means within 24 hours of the procedure; and that they have billed for them as a rule and always been paid (as we did). Others said they felt that the “before/prior to” meant any time, even weeks before, and they didn’t bill for them.

Is the “consulting/decision for surgery” visit to a specialist for a screening colonoscopy billable?
We understand that a pre-operative clearance/H&P after the decision for surgery is made, is not billable as it is not deemed medically necessary. But can we bill for the visit in which the patient meets the specialist, and a decision is made as to whether or a colonoscopy should be done or not?

Also, if the consult/decision for surgery is indeed billable, does it fall into the “day before/day of “rule where it’s not billable even with modifier 57, due to being a minor procedure, or is that rule only regarding pre-ops? Typically, our consults are done days to weeks prior to the scope, but sometimes it is more of a list-minute decision.

A

Medicare and most other insurers cover only medically necessary services. A patient is eligible for a screening colonoscopy if there are no signs or symptoms of GI trouble. It stands to reason that a pre-op clearance exam that finds no health care condition to support the medical necessity of the visit is not medically necessary, and therefore should not be billed, regardless of the timing (same day or not.) Medicare may have paid claims for such visits at the RHC in the past, but that doesn’t necessarily mean the visits have truly met the general test of medical necessity.

However, if there is a medically necessary reason for the visit, such as any other complicating condition that would be pertinent to the safety of the patient while undergoing the procedure (high blood pressure, diabetes, etc.), then the visit might be considered medically necessary. Medical necessity will be determined by the documentation and diagnosis coding provided in addition to the ICD10 Z01.81x (Encounter for preprocedural examinations.) 
Medicare defines an RHC visit as “medically necessary”.

The American Gastroenterological Association website also discusses this issue.

If the service is not a screening colonoscopy, then several other factors influence whether a pre-operative H&P visit should be separately reported and/or reimbursed:

  • Whether the E/M is performed by the same physician/same group practice who will perform the surgical procedure, and

  • Whether the decision for surgery has already been made at the time of the H&P; and

  • Whether the E/M is performed on the same day or the day prior to the surgical procedure, and

  • Whether the global period for the surgical procedure 10 days or less

  • Whether the service was medically necessary, in other words, were there conditions that required assessment before the patient could safely have surgery;

As you may already be aware, Medicare assigns a “global” period indicator of 000 to most colonoscopy codes − “000” − Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable.”

Surgeons may bill for a visit prior to surgery, as they need to evaluate the problem and determine the best surgical approach, but:

  •  If the global surgical period is greater than 10 days -- A preoperative examination by the same physician that will perform the surgery to clear the patient for surgery on the same day, or the day prior to surgery, is part of the global surgical package, and should not be reported separately

  •  If the procedure has a global period of 10 days or less, and the surgeon makes the decision to perform surgery during a visit which occurs within a day before the surgery, the surgeon may bill for an E/M with modifier 57 (decision for surgery), in addition to the surgery

  • If the procedure is preventive in nature, and there is no “problem” to report on a problem-focused visit, then the visit does not meet medical necessity

Another physician (not the surgeon) can bill for an H&P after the surgeon makes the decision to perform surgery, and refers the patient to a second physician (often a primary care physician) for a preoperative H&P.

This service is reportable, but if the visit is not deemed to be medically necessary, a payor may deny payment. Medical necessity will be determined by the documentation and diagnosis coding provided in addition to the ICD10 Z01.81x:

ICD-10 Codes
Codes and/or Descriptions: Z0181

ICD-10 Code

Description

Z0181

Encounter for preprocedural examinations

Z01810

Encounter for preprocedural cardiovascular examination

Z01811

Encounter for preprocedural respiratory examination

Z01812

Encounter for preprocedural laboratory examination

Z01818

Encounter for other preprocedural examination

The following matric was created to help simplify the various scenarios when a medically necessary pre-op exam would be billable:

Date of Pre-Op E/M

More than one day prior to surgery

Within one day of surgery with a Global Period of >= 10 days

Within one day of surgery with a Global Period of < 10 days

E/M performed by the same physician who will perform the surgery

Billable

Not billable

Billable only if Decision for Surgery made (modifier 57)

E/M performed by another (non-surgeon) provider

Billable

Billable

Billable

ParaRev can help

Proper coding and subsequent denials continue to be a challenge as hospitals and healthcare systems struggle with maintaining qualified personal, decreasing margins, and constantly changing requirements. A 2021 audit found that the average accuracy rate for E/M coding was just 81% for hospital billing and 75.3% for professional billing.[1] Regarding denials, hospital billing had an average initial denial rate of 34% while professional billing experienced a 15% rate.[2] In addition, missing modifiers could result in the loss on average of $170 (Professional claim), $690 (hospital outpatient claim), and $900 (hospital outpatient claim).[3]

ParaRev specializes in accounts receivable recovery and resolution and serves as a virtual extension of your hospital’s central billing office to help you quickly resolve and collect more of your insurance accounts receivable. The constantly changing codes and billing requirements can be hard to manage with finite resources. ParaRev’s Data Team can help ensure that changes are implemented in timely and accurately.

Contact ParaRev to learn more about how we can help you improve your hospital’s accounts receivable management.

  1. Healthcare Auditing and Revenue Integrity: 2021 Benchmarking and Trends Report. Hayes Management.
  2. Ibid.
  3. Ibid.

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The Top 10 Revenue Cycle Issues Facing Hospitals in 2022

Posted on by Jon Giuliani

February 16, 2022

Jon Giuliani
Vice President of Operations

  1. PRICE TRANSPARENCY.The back-end work is complex. The data requirements are enormous. And making a user-friendly and informative portal is daunting. Hospitals will require expert technical assistance. There will be a cost, but the cost of non-compliance outweighs the initial investment.
  2. LAB PAMA REPORTING.Medicare extended the deadline for certain hospitals and clinics which meet the description of an “Applicable Laboratory” to report private payer lab rates to the first quarter of 2023. It’s a reprieve–for now. But knowing if you’re one of those certain hospitals or clinics may require expert help.
  3. NO SURPRISES ACT.While providers and medical associations are voicing their disappointment in the NSA arbitration process, they are generally supportive of the NSA. That being said, implementing the requirement will continue to be a priority for hospitals.
  4. APPROPRIATE USE CRITERIA.Medicare moved the deadline for OPPS hospitals and interpreting radiologists to comply with reporting requirements to January 1, 2023. But that doesn’t mean hospitals can rest. Work throughout 2022 will be required to comply with these requirements.
  5. STAFFING CHALLENGES.The inability to adequately achieve a full cadre of qualified revenue cycle employees directly impacts a hospital’s cash flow and financial performance. This, in turn places immense pressure on capital and operational needs.
  6. ADMINISTRATIVE COSTS.Keeping the doors open will continue to drain resources and reserves as hospitals face rapidly rising administrative costs. The challenge for hospitals will be in finding ways to stem the tide of rising costs and potential red ink.
  7. AR RECOVERY & RESOLUTION.Exacerbated by staffing shortages, pursuing aging, small-balance claims will gain better success by using a dedicated, specialized team ensure quicker cash conversion and a reduction of bad debt reserves.
  8. CLAIM DENIAL MANAGEMENT.Hospitals will need to increase their reliance on intelligent automation and staff specialization to efficiently process all claims, regardless of size or age, for hospitals. This will contribute to cash flow and improved operational management.
  9. INVOICE & PAYMENT PROCESSING.Medical practices–whether hospital-owned or independent–cite patient collections as a top revenue cycle struggle. Providers are now challenged to create invoicing and payment systems that are easy for patients to use and that offer a variety of payment options. Providers are also required to follow strict guidelines to protect patient information, making it even more difficult to create a patient-friendly portal that encourages users to pay in a timely manner.
  10. IMPROVING THE PATIENT EXPERIENCE.Healthcare organizations face tough competition in attracting and retaining patients who demand an experience that matches the level of customer service they expect from other consumer experiences. For organizations offering a variety of services in different locations, it becomes even more challenging to provide accurate and up-to-date information from one centralized database. Here is where the patient portal becomes either most valuable, or most challenging.

ParaRev offers a full spectrum of healthcare revenue cycle management services, from front-end charge master analysis and contract management to end-of-cycle zero-balance denial recovery. We’re committed to working seamlessly with your hospital financial and billing staff to minimize denials and bad debt, improve collections and boost revenues.

ParaRev has three operational divisions focusing on the core pillars of the healthcare revenue cycle:

  • RevCap, the revenue capture services division, supports primary and secondary AR recovery resolution, targeted denial resolution and zero-balance underpayment recovery. 
  • RevTeg, revenue integrity services division, provides contract analysis, coding and compliance services and market-based pricing analysis. 
  • RevTek, the revenue technology services group, offers ParaPath, our revolutionary denial decision software, and ParaRev Data Editor, a robust web-based single source solution for pricing, coding, reimbursement, and compliance, along with price transparency, contract management and payer scorecard tools.

ParaRev’s comprehensive capabilities, when aligned with hospital internal teams, can help hospitals improve operating margins and collect additional revenue. Contact ParaRev for help in overcoming the top 10 issues facing hospitals and health systems in 2022!

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Revenue Cycle Executive Game Plan: Proven Automation Strategies that Deliver Results

Download our free whitepaper to learn how a 6-step end-to-end action plan can transform your revenue cycle operations.

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2022 Requirements for No Surprises Act: Updated

Posted on by Barbara Johnson

January 31, 2022

Barbara Johnson, BSN, RN, CPC, FHFMA
Senior Revenue Cycle Consultant

The No Surprises Act (NSA) is a federal law which went into effect on January 1, 2022. The law bans surprise medical bills for emergency services and elective care when the patient does not have a choice of ancillary service providers in an in-network facility.

The Department of Health and Human Services (HHS) has realized that not all aspects of the NSA will be able to be implemented by providers and facilities by January 1, 2022, so they have elected to exercise “enforcement discretion” on portions of the act in 2022. To be in compliance in 2022, healthcare providers and health care facilities must be prepared to:

  1. Publicize and disseminate a “Disclosure Notice” which informs beneficiaries of group health plans of their rights under the No Surprises Act; and
  2. Publicize and disseminate a “Right to Receive a Good Faith Estimate” to uninsured or self-pay patients; and
  3. Provide uninsured or self-pay patients with a good faith estimate (within a $400 threshold) of services that will be billed by the “convening” provider or facility.
  4. Present a Notice and Consent form, with an estimate of charges, to a beneficiary of a group health plan who chooses to receive services from an out-of-network facility or provider and submit a claim to the health plan.

Disclosure Notice

As of January 1, 2022, the disclosure notice must be prominently displayed on websites, in public areas of an office or facility, and on a one-page (double-sided) notice provided in-person or through mail or e-mail, as chosen by the patient. The disclosure notice must be provided to all commercially insured patients after January 1, 2022, or before that date if the elective service will be provided after January 1, 2022. The notice must be provided before requesting a payment from the insured or before a claim is submitted on behalf insured.

eCFR :: 45 CFR Part 149 — Surprise Billing and Transparency Requirements

screenshot of requirements
screenshot of requirements

In states where there are state laws that protect patients against surprise billing, providers and facilities can use a state disclosure notice if it meets or exceeds the federal guidelines. If a provider or facility drafts their own disclosure notice it must include these three points:

  1. Restrictions on providers and facilities regarding balance billing in certain circumstances
  2. Any applicable state laws protecting against balance billing
  3. Contact information for appropriate state and federal agencies if the individual believes their rights have been violated

Right to Receive a Good Faith Estimate Notice

All uninsured or self-pay individuals must be made aware, both orally and in writing, of their right to receive a good faith estimate for any services that will be rendered beginning January 1, 2022. The form must be prominently displayed on websites, in offices, and where scheduling or questions about the cost of health care may occur.

screenshot of "good faith estimate" section of no surprises act

Good Faith Estimates to Uninsured/Self Pay

When discussing the good faith estimate it is important to know a few terms:

  • A health care provider (provider) is defined as a physician or other health care provider who is acting within the scope of practice of that provider’s license or certification under applicable State law.
  • A health care facility (facility) is defined as a hospital or hospital outpatient department, critical access hospital, ambulatory surgical center, rural health center, federally qualified health center, laboratory, or imaging center that is licensed as an institution pursuant to State laws or is approved by the agency of such State or locality responsible for licensing such institution as meeting the standards established for such licensing.
  • The convening provider or facility is the one who receives the initial request for a good faith estimate from an uninsured or self-pay individual and who is or, in the case of a request, would be responsible for scheduling the primary item or service.
  • A co-provider or co-facility furnishes items or services that are customarily provided in conjunction with the convening provider.

An uninsured patient is an individual who does not have benefits for an item or service under a group health plan; whereas a self-pay patient is an individual who has benefits under a group health plan but chooses not to have a claim submitted to their plan. The good faith estimate presented to an uninsured or self-pay patient must include services reasonably expected to be provided by the convening provider or facility. At this time, estimates for services provided by co-providers and co-facilities do not have to be provided by the convening provider or facility.

The following list was provided in the interim final rule published in the Code of Federal Regulations. CMS followed up with a Fact Sheet that clarifies HHS will not be enforcing the requirement of including services provided by co-providers or co-facilities.

A good faith estimate must include:

  • Patient name and date of birth
  • Description of the primary item or service
  • Itemized list of items or services reasonably expected to be furnished
    • Items or services reasonably expected to be furnished by the convening provider or convening facility for the period of care; and
    • Items or services reasonably expected to be furnished by co-providers or co-facilities
  • Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service
  • Name, National Provider Identifier, and Tax Identification Number of each provider or facility represented in the good faith estimate, and the State(s) and office or facility location(s) where the items or services are expected to be furnished by such provider or facility
  • List of items or services that the convening provider or convening facility anticipates will require separate scheduling

eCFR :: 45 CFR Part 149 — Surprise Billing and Transparency Requirements

screenshot of eCFR 45

Requirements Related to Surprise Billing; Part II Interim Final Rule with Comment Period | CMS

screen shot of eCFR 45

The Good Faith Estimate process that requires facilities and providers to transmit estimates to health plans, is still on hold.

Notice and Consent

The Notice and Consent is being enforced for those rare instances when the patient has a choice of providers and chooses to receive services from an out-of-network facility or provider. Situations when a patient does not have a choice of providers and cannot be requested to sign a consent waiving their balance billing protections in an in-network facility are:

  • When receiving services that are considered ancillary services:
    • Items and services related to emergency medicine, anesthesiology, pathology, radiology, and neonatology
    • Items and services provided by assistant surgeons, hospitalists, and intensivists
    • diagnostic services, including radiology and laboratory services
    • Items and services provided by a nonparticipating provider if there is no participating provider who can furnish such item or service at such facility

Balance billing is prohibited in all emergency situations, even those that arise during a service that is being provided under a written consent. Any charges related to that emergency cannot be balance billed until the patient is deemed stable, as defined in the NSA – able to transport to another facility by nonmedical transportation. In the event the patient requires a higher level of care that requires transport, the EMTALA guidelines take precedence.

A patient admitted to an out-of-network facility from an emergency department who is then considered stable, must be presented with a notice and consent if they choose to continue treatment in the out-of- network facility. If the consent is signed, the out-of-network facility can balance bill for charges incurred after the provider documents that patient is stable, as defined in the NSA – able to transport to another facility by nonmedical transportation. Ancillary services cannot balance bill even after the patient is considered stable.

eCFR :: 45 CFR Part 149 Subpart E — Health Care Provider, Health Care Facility, and Air Ambulance Service Provider Requirements

screenshot of eCFR subpart e

The Notice and Consent form, with an estimate of all charges, must be presented to the patient for a signature.

  • This form must be available in the 15 most common languages in the geographical area. If the individual’s preferred language is not among those 15, a qualified interpreter must be made available to assist the patient with understanding their rights.
  • The form must be provided at least 72 hours prior to scheduled services, when they are scheduled at least 72 hours out. When services are scheduled and performed on the same day, the document is required to be presented at least 3 hours before the services are rendered.
  • The patient must be provided with a signed copy and a signed copy must be maintained in the medical record in the same manner as all other required documented.

ParaRev can Help

ParaRev has an online tool that can assist with estimates and notices. To learn more, contact us at 800-999-3332 and ask to speak with an Account Executive for more information.

ParaRev offers a full spectrum of healthcare revenue cycle management services, from front-end charge master analysis and contract management to end-of-cycle zero-balance denial recovery. We’re committed to working seamlessly with hospital financial and billing staff to minimize denials and bad debt, improve collections and boost revenues.

ParaRev’s comprehensive capabilities, when aligned with hospital internal teams, can help hospitals improve operating margins and collect additional revenue. Contact us to learn how we can help your facility meet the requirements of the No Surprises Act.

whitepaper cover page

Revenue Cycle Executive Game Plan: Proven Automation Strategies that Deliver Results

Download our free whitepaper to learn how a 6-step end-to-end action plan can transform your revenue cycle operations.

Download

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CMS Releases No Surprises Act – Part II

Posted on by Randi Brantner

October 22, 2021

Randi A Brantner, MBA-HA
Vice President of Analytics

On September 30, 2021, the Department of Health and Human Services (HHS), the Department of Labor, and the Department of Treasury released Part II of the “No Surprises Act” which was published in the Federal Register on October 7. The Act, which goes into effect on January 1, 2022, aims to protect patients from unexpected out of pocket costs resulting from surprise and balance billing.

Part II of the Act addresses plan coverage requirements, independent dispute resolution processes between the payers and providers, and details for how payers will determine patient cost-sharing responsibilities.

The Centers for Medicare & Medicaid Services (CMS) devotes a website to the No Surprises Act, Ending Surprise Medical Bills, which covers policies and resources, help with resolving payment disputes, and information on consumers rights and protections.

On September 31, CMS published a Fact Sheet, Requirements Related to Surprise Billing; Part II Interim Final Rule with Comment Period. Previously, CMS published a Fact Sheet covering Part 1, Requirements Related to Surprise Billing; Part I Interim Final Rule with Comment Period, on July 1, 2021.

Pararev can help

An essential component of the “No Surprises Act” is the ability for the provider to deliver pricing transparency to the consumer. Meeting the challenges of pricing transparency demands a systematic approach grounded in empirical evidence and a capable staff implementing proven solutions. Pararev, a leader in accounts receivable recovery and resolution, can help you execute all steps necessary to comply with the transparency rule and improve patient satisfaction. To see how this solution would work for your hospital, click here to view a short demo.

Contact us today to learn more about how we can help your organization prepare for the pricing transparency requirement that is a critical component of the “No Surprises Act”.

Overcome the challenges of hospital pricing and revenue cycle management for improved revenue capture and better margins. Download our whitepaper to discover 3 ways to accelerate your financial transformation!

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Appropriate Use Compliance Deadline Delayed

Posted on by Barbara Johnson

October 20, 2021

Barbara Johnson, BSN, RN, CPC, FHFMA
Senior Revenue Cycle Consultant

In 2019, the Centers for Medicare & Medicaid Services (CMS) announced that calendar year 2020 would serve as a “test and educate” period during which providers billing for advanced imaging studies are required to report whether the ordering physician consulted a clinical decision support mechanism. The requirement to report the informational codes is currently in effect, but Medicare will not yet impose penalties for failure to report, or for incorrect reporting. (The requirement does not apply to Critical Access Hospitals). The Appropriate Use Compliance (AUC) program was authorized by the Protecting Access to Medicare Act of 2014 (PAMA) to promote the use of AUC and decrease the number of inappropriate advanced diagnostic imaging services provided to Medicare beneficiaries.

Ordering physicians (or clinical staff acting at the physician’s direction) will consult the AUC using a clinical decision support mechanism (CDSM). The CDSM is an interactive, electronic tool that is either stand-alone or integrated into an electronic health record (EHR). When queried, it provides a response indicating that the advanced diagnostic imaging service is appropriate, not appropriate, or not applicable for the patient. The AUC requirements apply to advanced diagnostic imaging services (CT, PET, MRI, and Nuclear Medicine) provided in physician offices, hospital outpatient departments (including emergency departments), ambulatory surgical centers, and independent diagnostic testing facilities.

Consulting CDSMs exceptions

CMS released an MLN Matters article in July 2019 that includes the imaging HCPCS codes, the G-codes for the CDSMs, and AUC modifiers. There are a few exceptions to the requirement to consult the CDSM, which are:

  • Emergencies
  • Inpatient advanced diagnostic imaging services
  • Ordering physician meets hardship exception
    • Hardship exceptions include:
      • Insufficient internet access
      • EHR or CDSM vendor issues
      • Extreme and uncontrollable circumstances

If an exception exists, the physician will include it with the order and the furnishing physician will report the corresponding modifier on the claim.

AUC Requirements

After the physician has consulted the CDSM and ordered the advanced diagnostic imaging service, the following data will be sent, with the order, to the provider completing the imaging service:

  • The CDSM consulted by the ordering physician.
  • Whether the service adhered to the applicable AUC, did not adhere to the applicable AUC, or whether no criteria in the CDSM were applicable to the patient’s clinical scenario.
  • The National Provider Identifier (NPI) of the ordering physician. CMS maintains a list of qualified CDSMs on its website at Clinical Decision Support Mechanisms | CMS.

The following list was posted on August 30, 2021:

Mechanism NameCode
eviCore healthcare’s Clinical Decision Support MechanismG1001
MedCurrent OrderWiseTMG1002
Medicalis Clinical Decision Support MechanismG1003
National Decision Support Company CareSelectTM*G1004
AIM Specialty Health ProviderPortal®*G1007
Cranberry Peak exCDSG1008
Sage Health Management Soluntions Inc RadWise®G1009
Stanson Health’s Stanson CDSG1010
Radrite*G1011
AgileMD’s Clinical Decision Support MechanismG1012
EvidenceCare’s Imaging AdvisorG1013
InveniQA’s Semantic Answers in MedicineTMG1014
Reliant Medical Group SCSMG1015
Speed of Care CDSMG1016
HealthHelp’s Clinical Decision Support MechanismG1017
INFINX CDSMG1018
LogicNets AUC SolutionG1019
Curbside Clinical Augmented WorkflowG1020
E*HealthLine Clinical Decision Support MechanismG1021
Intermountain Clinical Decision Support MechanismG1022
Persivia Clinical Decision SupportG1023

New Advanced Diagnostic Imaging HCPCS Modifiers

Medicare also released eight new modifiers to be appended to the imaging HCPCS when an advanced diagnostic imaging is billed. The modifiers indicate the clinician’s use (or non-use) and compliance with a CDSM when ordering advanced diagnostic images.

Modifiers to be appended to Advanced Diagnostic Imaging HCPCS on Medicare Outpatient Claims

ModifierShort DescriptorLong Descriptor
MAEmer med cond susp/confirmOrdering professional is not required to consult a clinical decision support mechanism due to service being rendered to a patient with a suspected or confirmed emergency medical condition
MBAUC hardship, insuf internetOrdering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of insufficient internet access
MCAUC hardship, vendor issuesOrdering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of electronic health record or clinical decision support mechanism vendor issues
MDAUC hardship, extreme circOrdering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of extreme and uncomfortable circumstances
MEOrder adheres to AUCThe order for this service adheres to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional
MFOrder does not adhere to AUCThe order for this service does not adhere to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional
MGAUC not applicable to orderThe order for this service does not have applicable appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional
MHAUC consult not providedUnknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider
a data table in medical billing software


The excerpt below illustrates the mandatory reporting for a CT of the head billed to Medicare on a UB04:

AUC workflow requirements

The following is the workflow for meeting the AUC requirements:

  • The physician sees a Medicare beneficiary and plans to order an advanced diagnostic imaging service
  • The physician (or clinical staff under the direction of the physician) consults the AUC for the proposed advanced diagnostic imaging service through a CDSM. The CDSM can be integrated into the EHR or a separate portal
    • If a hardship exception exists, the physician will include it with the order
  • The CDSM will search for and present the AUC relevant to the patient’s condition
  • The CDSM response will indicate if the proposed advanced diagnostic imaging service:
    • adheres to the AUC, or
    • does not adhere to the AUC, or
    • if there is no applicable AUC
  • If it adheres to the AUC, the physician will proceed with the order
  • If it does not adhere, the physician must decide to order a different imaging service or proceed with the proposed service despite it not adhering to the AUC
  • The physician orders the advanced diagnostic imaging service and includes with the order:
    • the CDSM queried, and
    • the AUC response, and
    • the physician’s NPI
  • The rendering provider furnishes the imaging service to the patient
  • The rendering provider reports in the professional and institutional claims:
    • HCPCSG-code associated with the CDSM, and
    • The applicable AUC modifier, and
    • the ordering physician’s NPI

Analysis of ordering physician practices

The outcome of this program will be to analyze the ordering practices of the physicians and determine any outliers. PAMA calls for identification on an annual basis of no more than five percent of the total number of ordering physicians who are outliers. The use of two years of data is required for this analysis. Data collected during the education and testing period will not be used when identifying outliers. Outliers will be determined based on low adherence to applicable AUC or comparison to other ordering physicians. Physicians who are found to be outliers will be required to complete prior authorizations for advanced diagnostic imaging services.

The following clinical areas will be the focus of the analysis of outliers:

  • Coronary artery disease (suspected or diagnosed)
  • Suspected pulmonary embolism
  • Headache (traumatic and non-traumatic)
  • Hip pain
  • Low back pain
  • Shoulder pain (to include suspected rotator cuff injury)
  • Cancer of the lung (primary or metastatic, suspected or diagnosed)
  • Cervical or neck pain

Compliance Assistance

Pararev can provide compliance assistance to help you navigate the Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging regulation.

Pararev is a revenue cycle solutions provider that offers price transparency, reimbursement, revenue integrity/coding, and compliance support. Comprised of seasoned professionals and equipped with a web-based cloud computing engine, the Pararev Data Editor (PDE), they analyze, identify, repair, and improve the revenue cycle processes to support Providers in achieving their financial goals.

Pararev is comprised of a team of coders, compliance experts, financial analysts, and IT professionals with extensive experience in focused disciplines to support the revenue cycle process. In fact, on average, our consultants have over 21 years of healthcare experience, allowing them to support clients with experience from the trenches. Pararev’s services range from a web-based revenue cycle tool to a comprehensive revenue integrity program complete with a chargemaster audit, pricing services, monthly department meetings, and ongoing pricing, coding, reimbursement, and compliance support.

Contact us to learn more about how we can help you navigate today’s healthcare compliance concerns including the Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging regulation and more.

Zero-balance claims reviews represent a final safety net that can generate hundreds of millions of dollars for hospitals

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5 Steps to Uncovering Lost Revenue – Taking Control of your Denials

Posted on by Kevin Lee

September 22, 2021

Kevin Lee
President of STAT Revenue

The COVID-19 pandemic has had a dramatic impact on many providers’ revenue cycles, with sharply lower patient and procedure volumes triggering major cash flow problems across a range of organizations. Although the situation has stabilized for most, finding ways to reduce denials and ensure you’re paid every dollar you’re entitled has never been more important.

Denial Reality

Even before the pandemic, denials were a major and costly problem in healthcare. Consider:

  • Denial volume increased by 79% for the average hospital between 2011 to 2017 [1]
  • A recent survey of hospital executives found that 30% of responding facilities had bad debt of between $10 million and $50 million, while 6% reported bad debt of greater than $50 million [2]
  • 9% of $3 trillion in U.S. hospital claims ($270 billion) were initially denied in 2016 [3]
  • Hospitals expend $9 billion annually in administrative costs for rework denials [4]
  • It takes 5-12 minutes per claim to check status manually [5]
  • The average cost of each claim status check by providers is $5.40 [6]

Despite the growing prevalence of denials, the fact remains that 90% of claims are preventable and 66% are recoverable. Even so, 65% of claim denials are never corrected and resubmitted for reimbursement. [7]

Here are five ways to take control of your denial problem:

Step 1: Optimize the Effectiveness of Your Current AR Process

While hospitals continue to face rising accounts receivable (AR) balances due to denied, unpaid and underpaid commercial insurance claims, adding staff to pursue denials can be costly and may still result in many low-dollar, high-volume claims going unworked.

A virtual extension of your central billing office’s resources can help bolster your efforts with a dedicated, knowledgeable, and responsive team of experts who have specific experience with your payers. This additional capability, integrated seamlessly with your systems, can decrease cycle time, and help ensure all claims, no matter the age or balance, are effectively worked to 100% resolution.

Step 2: Develop a Hard Dollars Collection Strategy

An effective AR management strategy should incorporate processes to pursue claims at key aging intervals, so no denials fall through the cracks. Typically, hospitals can task their primary AR management firm with claims that have aged from 30 to 90 days before sending older claims to the pre-write-off insurance collection specialist. Alternatively, hospitals can task internal staff with new claims, then turn any remaining inventory over to a pre-write-off insurance collection vendor.

Ultimately, you want to develop a strategy to collect the extremely aged hard dollars or dollars already written off (zero balance) so that you can improve collections and verify that claims are truly uncollectable and may be removed from the balance sheet.

Step 3: Pursue Pre-write-Off Insurance Collection

Secondary assigned accounts or second placement AR services for pre-write-off insurance collections provide a critical safeguard to ensure no insurance payments legitimately due to the hospital go uncollected, regardless of age. The benefits of enlisting this kind of outsource capability include:

  • The establishment of an AR management process that offers a systematic approach to obtaining 100% claims resolution
  • A reduction in write-offs, a commensurate increase in cash flow and a decrease in bad debt reserves caused by aging accounts
  • The creation of incentives that push primary AR vendors to optimize their processes
  • Greater transparency to enable hospitals to evaluate performance across the entire revenue cycle

To learn more about reducing write-offs, click here.

Step 4: Conduct Zero-Balance Reviews

Specialized, forensic audits of written-off (zero balance) claims compare payments received to anticipated revenue based on episode-of-care specifics, coding best-practices, and payer-provider contractual terms. Any underpaid claims are resubmitted, per the payer’s terms, for reimbursement.

Recovered underpayments from zero-balance reviews can total up to 1% of a hospital’s annual Net Patient Revenue, an amount that may be significant for large hospitals and health systems that generate hundreds of millions of revenue annually. A zero-balance audit and recovery process should include training or education to help hospital staff mitigate systemic or reoccurring coding and process errors uncovered during the initial review.

Click here to learn more about how zero-balance claims reviews can be a critical backstop for AR management strategies

Step 5: Develop a Process to Identify the Root Cause of All Denials

No matter where collections are pursued in the revenue cycle, one of the most important steps you can take in developing a robust accounts receivable strategy is determining the root cause of delayed, underpaid or denied claims. Unfortunately, hospital personnel and many primary vendors frequently don’t have the time or technology to determine the precise underlying reason for the denial.

Partnering with a vendor that utilizes intelligent automation can help systematically isolate denials by type, age and size before all claims are worked to resolution. This time-saving process also helps identify exactly where in the revenue cycle the initial problem occurred so proactive measures can be taken to prevent it from happening again.

To learn 7 strategies for preventing up to 90% of denials, click here.

Protect Your Revenue

While it’s best to resolve and collect outstanding accounts receivable before they become highly aged, this isn’t always practical in today’s challenging reimbursement environment. By adopting a comprehensive and aggressive accounts receivable strategy to ensure hospitals receive all the money they’re due from payers, facilities can experience significant reductions in bad debt and write-offs and a corresponding increase in cash flow and margins.

Pararev can help you progress toward the goal of zero-percent write-offs through our comprehensive AR solutions. We’re able to resolve all claims, regardless of size or age quickly, and conduct zero-balance reviews to ensure you’re collecting every dollar you deserve. Contact us today to learn more.

  1. Kelly Gooch, “4 ways hospitals can lower claim denial rates,” Becker’s Hospital CFO Report, Jan. 5, 2018.
  2. “Bad Debt Exceeds $10M at a Third of Organizations, But Lack of Confidence Exists in How Much is Recoverable,” Cision PR Newswire. June 19, 2918.
  3. Philip Betbeze, “Claims Appeals Cost Hospitals Up to $8.6B Annually” HealthAffairs, March 16, 2021.
  4. ibid.
  5. ibid.
  6. ibid.
  7. Chris Wyatt, “Optimizing the Revenue Cycle Requires a Financially Integrated Network,” HFMA, July 7, 2015.

Overcoming the denial dilemma with intelligent automation. Learn how by downloading our whitepaper.

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CMS Raises the Stakes on Price Transparency Compliance: issues new civil monetary penalties

Posted on by Randi Brantner

September 8, 2021

Randi A Brantner, MBA-HA
Director, Financial Analytics

In effect since January 1 of this year, recent studies are showing low compliance with meeting all aspects of the Health Care Price Transparency Act. JAMA Internal Medicine published an article in June that showed 75 percent of the 100 top-grossing hospitals didn’t comply with at least one of the rule’s requirements while 86 percent had a price estimator tool. Fifty percent of 100 randomly sampled hospitals had a price estimator tool and of those 100 hospitals, 83 percent failed to comply with at least one of the rule’s requirements.[1] In another study of 5,288 hospitals, it was found that only 48.5 percent had chargemaster data on their websites with only 138 hospitals having an online price estimator.[2] A study based on bed count and published in HealthAffairs, found 65 percent of the 100 largest hospitals in the U.S. were not in compliance and 12 of the noncompliant hospitals had no files or links to searchable databases.[3]

CMS implements civil monetary penalties for noncompliance

As a result of this widespread noncompliance, the American Hospital Association (AHA) released a Member Advisory regarding noncompliance with the Centers for Medicare & Medicaid Services (CMS) Hospital Price Transparency requirements. In it, they noted that CMS has launched proactive audits of hospital websites and have evaluated complaints presented to CMS by consumers. According to the publication, CMS started with auditing larger acute care hospitals and have now expanded their examination of random hospitals. The first set of warning letters were issued the week of April 19th. However, CMS has indicated that they will not announce the list of hospitals that have received warning letters but will publish the identities of the hospitals that remain non-compliant and receive a monetary penalty if they have not addressed the issues within 90 days.

Number of Hospital BedsMaximum Annual Civil Monetary Penalty
<30$109,500
50$182,500
100$365,000
200$730,000
300$1,095,000
400$1,460,000
500$1,825,000
500+$2,007,500

A Special Edition from the Medicare Learning Network states that CMS is updating the civil monetary penalty amount. The current minimum civil monetary penalty of $300/day would apply to smaller hospitals with less than 30 patient beds. However, for hospitals with more than 30 beds, the penalty will be $10/bed/day, not to exceed a maximum daily dollar amount of $5,500. “Under this proposed approach, for a full calendar year of noncompliance, the minimum total penalty amount would be $109,500 per hospital, and the maximum total penalty amount would be $2,007,500 per hospital.”[4]

Patients and hospitals can submit a complaint to CMS if they believe a hospital doesn’t have the appropriate information posted online. For more information on Hospital Price Transparency, click here. If you have any other questions regarding Hospital Price Transparency, email the hospital price transparency team.

Hospital price transparency requirements

As a reminder, the CMS Hospital Price Transparency rule requires that hospitals publish detailed pricing information online to help consumers make accurate cost comparisons for a range of treatments and procedures. The rule contains two types of price transparency requirements:

  1. Hospitals must post their entire array of standard charges online in a machine-readable file that is easily accessible from their public website
  2. Hospitals must publish a document listing pricing for 300 specific shoppable healthcare services. Of these 300 items, 70 have been pre-defined by CMS, while the remaining 230 can be selected at the discretion of the hospital.

For both requirements, a range of different price categories must be shown, including gross charges, payer-specific negotiated rates, self-pay discounted rates, and de-identified minimum and maximum negotiated charges. The files also must contain any ancillary charges that are customarily included for the specific shoppable service, such as the costs associated with additional related procedures, tasks, allied services, supplies, or drugs, as well as any professional fees billed separately from the facility bill.

These requirements present challenges when it comes the sheer data mining and payer contract analytics required to deliver on the mandates. A hospital’s payer contract modeling system must be able to accommodate a variety of settlement methodologies by patient type including MS-DRG, APR-DRG, EAPG, ASC Levels, APC packaging, and percent of charge, among others. This means that for a typical hospital with a 10,000-line chargemaster, seven patient types, and 20 payer contracts, over 1.4M calculations are needed to fulfill the mandate. Meeting the regulatory requirements of the Health Care Price Transparency Act could require a hospital to spend an extraordinary amount of time and resources that they might not have. An alternative would be to contract with a partner that could provide the expertise with a cost-effective solution.

PARA HealthCare Analytics can help

PARA HealthCare Analytics, an ParaRev Company, is among the leaders in supporting hospitals in achieving readiness for CMS Price Transparency regulations, which will help consumers make more informed healthcare purchasing decisions. To ensure consumers will be able to browse for healthcare services in the same way they shop for other goods and services online, PARA has developed robust and accurate pricing capabilities for area healthcare consumers. The PARA solution includes a patient-facing estimator that delivers user-friendly, procedure-level estimates reflecting patients’ specific coverage limits and is updated quarterly for the facility with a payer contract system that can accommodate a variety of settlement methodologies.

PARA’s Price Transparency Tool, which uses the actual payer contract language as outlined in the CMS requirements to make those millions of calculations, is the most cost-effective and comprehensive solution on the market today.

To see how this solution would work for your hospital, click here to view a short demo.
And for more detail on the CMS requirements 1 and 2, watch our Becker’s Webinar: Price transparency – clarifying the unknown.

We can help you refine your pricing to improve revenue capture and strengthen margins while remaining competitive in your market. Contact us today to learn more about how we can help your organization prepare for the transparency transformation ahead.

  1. Suhas Gondi, BA1,2; Adam L. Beckman, BS1,2; Avery A. Ofoje, BA3; et al., “Early Hospital Compliance With Federal Requirements for Price Transparency,” JAMA Internal Medicine, June 14, 2021.
  2. Waqas Haque, MPH, MPhil1; Muzzammil Ahmadzada2; Hassan Allahrakha, BS3; et al, Eman Haque4; David Hsiehchen, MD, “Transparency, Accessibility, and Variability of US Hospital Price Data.,” JAMA Network, May 14, 2021.
  3. Morgan Henderson, Morgane C. Mouslim, “Low Compliance from Big Hospitals on CMS’s Hospital Price Transparency Rule” HealthAffairs, March 16, 2021.
  4. “CMS Proposes Rule to Increase Price Transparency, Access to Care, Safety & Health Equity” mlnconnects, July 19, 2021.

Overcome the challenges of hospital pricing and revenue cycle management for improved revenue capture and better margins. Download our whitepaper to discover 3 ways to accelerate your financial transformation!

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No Surprises Act “Part 1” Regulation Issued

Posted on by Randi Brantner

August 19, 2021

Randi A Brantner, MBA-HA
Vice President of Analytics

Background: Federal law is required to prevent “surprise” billing

In 2020, Congress held meetings to determine whether laws should be enacted to prevent the devastating financial obligations imposed on a patient with healthcare insurance who is treated by an out-of-network provider, particularly when the patient did not know or expect that insurance coverage would be limited for that care.

During Congressional hearings, citizens recounted unexpected, and devastating, financial obligations incurred by patients who were transported by out-of-network air ambulance services. According to the Nebraska Department of Insurance, the average air ambulance trip is 52 miles and costs between $12,000 to $25,000 per flight. Since most air ambulance services do not participate as “network” providers with insurers, that portion of the bill that the insurer will not cover becomes a patient liability. The plight of these patients and others convinced Congress that federal law should prevent a “surprise” bill resulting from an uninformed patient owing large sums of money to an out-of-network provider.

“No Surprises Act” is added to the Consolidated Appropriations Act of 2021

The resulting legislation, the “No Surprises Act”, was incorporated into the Consolidated Appropriations Act of 2021, which was signed into law by then-President Trump in late December 2020. The new Federal law limits the ability of both insurers and out-of-network providers to shift a significant financial obligation to the patient/beneficiary, unless that patient is provided with advance written notice of the anticipated amount that the patient will owe, along with information about the patient’s alternatives to out-of-network care. If there is a State law that addresses the same concern, State law takes precedence.

Interim Final Rule recently released

The new law becomes effective on January 1, 2022, and the Office of Personnel Management, along with the Department of Health and Human Services, Labor, and Treasury developed implementing regulations. The first regulations, dubbed “Part 1”, were released on July 1, 2021 in an “Interim Final Rule with Comment Period” (CMS-9909-IFC.)
Stakeholders should pay particular attention to provider obligations arising from the law, including:

  • Distributing standard information about patient rights under the No Surprises Act Information must be posted on the provider website, in signage in public areas of the facility, and in a written one-page, double-sided document distributed to insured patients prior to collecting payment from the patient or submitting a claim to the patient’s group health insurer. (A model notice is under development.)
  • The “Notice and Consent” requirements of No Surprises Act Out-of-network providers and facilities must obtain the patient’s informed consent to collect out-of-network costs from the patient. The notice requirements include an estimate of the costs the patient will be liable to pay and information about in-network service alternatives. Notices must be available in the 15 most common languages spoken in the provider’s region. (It is not clear whether a provider may simply opt-out of the notice requirement and accept whatever the insurer’s discounted payment rate may be.)
  • The method insurer must use to calculate the “Qualifying Payment Amount” for out-of-network services The payment the insurer is obligated to use in calculating provider reimbursement and patient liability for services at an out-of-network provider could be based on that insurer’s median in-network contracted rates with other like providers within the same region, depending on specific circumstances

The second set of implementing regulations, “Part 2”, are expected to be published in coming months relating to dispute resolution and other provisions of the new law.

Additional Resources

To learn more about the No Surprises Act and the regulations implementing the new law, visit the following websites:

  • Interim Final Rule, CMS-9909-IFC, published on7-13-21 in the Federal Register
    • Subpart E – Health Care Provider, Health Care Facility, and Air Ambulance Service Provider Requirements
      • 149.410 Balance billing in cases of emergency services.
      • 149.420 Balance billing in cases of non-emergency services performed by nonparticipating providers at certain participating health care facilities.
      • 149.430 Provider and facility disclosure requirements regarding patient protections against balance billing.
      • 149.440 Balance billing in cases of air ambulance services.
      • 149.450 Complaints process for balance billing regarding providers and facilities.
  • CMS: “Fact Sheet” on the interim final rule
  • The American Hospital Association: concise summary and analysis
  • The American Medical Association: high-level summary
  • United Healthcare: convenient FAQ-style resource on its website
  • No Surprises Campaign (People against Unfair Medical Bills): consumer stories and letters from diverse interests participating in the development of the No Surprises Act

ParaRev can help

An essential component of the “No Surprises Act” is the ability for the provider to deliver pricing transparency to the consumer. Meeting the challenges of pricing transparency demands a systematic approach grounded in empirical evidence and a capable staff implementing proven solutions. ParaRev, a leader in accounts receivable recovery and resolution, can help you execute all steps necessary to comply with the transparency rule and improve patient satisfaction. To see how this solution would work for your hospital, click here to view a short demo.

Contact us today to learn more about how we can help your organization prepare for the pricing transparency requirement that is a critical component of the “No Surprises Act”.

Overcome the challenges of hospital pricing and revenue cycle management for improved revenue capture and better margins. Download our whitepaper to discover 3 ways to accelerate your financial transformation!

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Comprehensive 2022 Billing Guide for Covid-19

Posted on by Nikki E Graves, MBA, CHFP

January 5, 2022

Nikki E. Graves, MBA, CHFP
Senior Revenue Cycle Consultant

The COVID-19 pandemic continues to cause extreme financial hardship for hospitals, health systems and all providers. Hospital operating margins through October 2020 fell 18.7%[1] while claim denials increased on average by 23 percent in 2020 compared to 2016[2]. These market dynamics make it even more important to stay abreast of regulatory changes regarding COVID-19.
With the pandemic has come increased and frequently changing COVID-19 regulations and guidelines. To help you stay on top of these changes, PARA HealthCare Analytics, a division of Healthcare Financial Resources, continues to update COVID-19 coding and billing information from the Centers for Medicare and Medicaid (CMS) and payers.

What you will find in this important update

  • Link to the CDC ICD-10 tool
  • Updated information on Remdesivir
  • FDA-approved COVID-19 treatment for most adults
  • New Medicare Administrative Contractor (MAC) payment link and table for pricing of COVID-19 lab tests
  • Updated language for Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) regarding billing of monoclonal antibodies (MAB) and vaccines
  • Easier to read sections for condition codes and modifiers
  • New information on controlled release and controlled delivery
  • Additional coding information related to COVID-19

To read the full Covid-19 coding document, click here.

Keeping it all straight

Staying abreast of the latest COVID-19 coding regulations can be a challenge, and it can be doubly so during the pandemic when resources may be tight. That’s why ParaRev keeps you updated on all the latest COVID-19 coding initiatives. Together, PARA and ParaRev deliver comprehensive revenue cycle services to support accurate coding, clean claims, accounts receivable recovery and resolution services, and timely and appropriate reimbursement. Contact us today to learn more about the many ways we can help your organization.

  1. Robert King, “Hospital operating margins down nearly 20% since start of year due to COVID-19, report says,” Fierce Healthcare, Nov, 30, 2020.
  2. Jacqueline LaPointe, “Hospital Claim Denials Steadily Rising, Increasing 23% in 2020,” Revenue Cycle Intelligence, Feb 4, 2021.

Overcome the challenges of hospital pricing and revenue cycle management for improved revenue capture and better margins. Download our whitepaper to discover 3 ways to accelerate your financial transformation!

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Five Tips to Working with Blue Cross and Blue Shield of Illinois

Posted on by Kurt Prins

August 3, 2021

Kurt Prins
Senior Client Program Manager

A health insurance company as prominent as Blue Cross Blue Shield (BCBS), having over 62 million members across all 50 states, provides high potential for revenue generating opportunities for any hospital Central Billing Office (CBO). According to the 2020 census, there are 12.8 million people living in the state of Illinois with 80 percent of that population enrolled with BCBS of Illinois. Based on these statistics, that would suggest that 10.2 million residents in Illinois are enrolled for healthcare coverage through BCBS. In terms of a business perspective on a revenue standpoint, BCBS of Illinois coverage should always be a high focus for any facility solely for the revenue aspect when patients are seen.

Tip 1: Understanding your EDI clearinghouse

All hospitals throughout Illinois should have an intimate understanding of what is required from front-end registration to denial management to streamline revenue as best as possible for this large number of insured individuals with one carrier. BCBS of Illinois requires the use of an insurance web portal or clearinghouse, so it is important to understand the range of products that portal provides. This will help maximize efficiency and avoid unnecessary denials to keep aging clean and healthy for this large volume carrier.

Tip 2: Checking eligibility – the key to clean claims

On a front-end/registration point of view, utilizing running eligibility is a simple starting point to ensure your claims are being sent to the appropriate address. Whether a patient’s coverage is through an Independent Practice Association (IPA), Managed Care Organization (MCO), Labor Fund, Federal or traditional BCBS, checking eligibility is the first step to avoid any unnecessary submissions or claim status inquiry attempts.

Tip 3: Utilizing AIM to help decrease denials

After eligibility is confirmed and the patient’s benefits based on the services have been provided, utilizing the AIM portal within the insurance web portal is another excellent tool for preauthorization purposes. The AIM portal allows you to look up the services a patient is scheduled to receive and verify if that specific CPT® code requires a preauthorization. As a vendor, the most common denials we see with our hospitals are specifically from the clinical denial aspect. This denial category would pertain to no authorization, medical necessity, level of care, and length of stay. With utilizing the AIM portal, this will provide an opportunity to minimize no authorization denials with a simple check if the scheduled services require an authorization or not. If your facility is not aware of this, please reach out to your provider representative to provide you this information. On a medical necessity standpoint, you may also utilize the AIM portal to initiate a peer-to-peer review for level of care or length of stay denials in efforts to overturn these denials received.

Tip 4: Improving follow-up efficiency and accuracy

Follow-up efficiency and accuracy is also important when dealing with this high-volume carrier. With roughly 10.2 million members, traditional BCBS of Illinois receives enormous amounts of calls a day regarding claim status inquires. Using an insurance web portal’s claim status tool for all claim status inquires prior to calling can help reduce unnecessary calls. This tool provides the opportunity to capture all key and necessary information needed to grasp a rough understanding of all claim status inquires. There may be times that the information captured may not be sufficient in terms of a progressive standpoint to verify if recent submitted disputes or documents are under review. Utilizing the CIR, or Claim Inquiry Resolution tool, is another effective way to verify an updated status of documents or disputes submitted, which is provided with a reference number for tracking purposes to ensure all inquiries are answered in a timely manner. Utilizing this tool helps reduce call volumes along with decreased hold times. Not only will this tool assist the efficiency of any CBO staff member but will also help vendors as well.

Tip 5: Understanding contractual reimbursement agreements

Some believe that BCBS pays at 100% of billed charges when in fact that is not the case. Typically, what happens is that it appears payments are paid in full within an Electronic Medical Records (EMR) system but in reality, the contractual adjustment is applied on the back end through the UPP Program. The Uniform Payment Program (UPP) in a sense is the contractual reimbursement solely for BCBS and individual facilities. The UPP discount can range from 25 percent to 70 percent based on services provided or the facility in general. It is encouraged to speak to your provider representative or your internal contract management department if you do not have a clear understanding of the discount BCBS of Illinois has with your facility.

Streamlining BCBS accounts

In conclusion, BCBS of Illinois provides countless opportunities to streamline this book of business with your CBOs and your vendors to help improve efficiencies which in turn will increase your revenue. Accurately utilizing all tools that BCBS and an insurance web portal provide is another opportunity to decrease denial volumes thus reduce aging. Any specific questions you may have, it is highly encouraged to reach out to your provider representative that will allow you to make your CBO and vendors more successful.

ParaRev can help

ParaRev has the expertise in working with BCBS not only in Illinois but across the country.
Our experts have a thorough knowledge of each state’s requirements and can help you with comprehensive revenue cycle services to support accurate coding, clean claims, and timely and appropriate reimbursement. Contact us today to learn more about the many ways we can help your organization.

Download our free whitepaper that discusses four key areas hospitals can address right now to mitigate or reverse revenue losses during the pandemic.

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