Medical rehabilitation billing may be the only source of revenue for rehabilitation centers, but it is also a vital part of billing and coding for physical therapy groups, multi-specialty physician groups, private and group practices, and hospitals.
The challenges faced by all healthcare organizations apply to rehabilitation billing, but there are some situations that may be especially relevant. Physical therapists and occupational therapists alike struggle to get adequate compensation, and the overall process has not become much easier despite updates and changes to regulations and billing codes.
Read also: How billing companies can save rehab facilities money
The impact of COVID-19 continues
The new year has come with no cure for COVID-19 discovered by the expected 2021, and the number of new cases continues to rise. The situation seemed to calm down in the summer, but the number of new cases in major cities has skyrocketed.
Then came Thanksgiving, the busiest travel season of the year, when many people who had been in close contact since the coronavirus lockdown began visited family in other states. Perhaps the numbers, which had been stable for some time, gave us a false sense of security, or people were simply patiently waiting to see their loved ones, but travel and group gatherings meant the virus was spreading. It found new circles.
But regardless of the reason for the spread, COVID-19 patients will need rehabilitation services until a new vaccine is widely available and proven effective. From a business perspective, COVID-19 patients generate revenue just like any other patient, but there will likely be more changes to billing codes and regulations than usual, and changes may also occur due to the COVID-19 emergency declaration. Much sooner than usual.
Providers are being asked to adapt to change, and as regulations change and billing practices lag, revenue will be lost. In these circumstances, outsourcing billing for regenerative procedures to a specialized billing company can be particularly advantageous.
As healthcare providers, therapists need to be able to focus on patient care, not administrative tasks. Those who provide healthcare in this economy cannot afford to lose revenue due to mistakes in filling out applications or not having enough time to follow up with rejected patients. Applications are rejected.
Surprise medical bills remain a problem.
The problem of insurance companies and government payers excluding some treatments from coverage has always been there, and patients are never happy with unexpected bills. This issue gained widespread attention in 2020 because people knew that insurance companies were being ordered by the government to cover the costs of COVID-19 treatment, so they did not expect large bills to come.
Viral infections can quickly become life-threatening, and with limited treatment options, many patients were transported by ambulance or ambulance, which resulted in high costs. Transportation costs are not included in the cost of care, so many patients receive unexpected, expensive bills. Surgical assistants and physical therapists can also face surprise medical bills if they work for a hospital or other clinic but are not covered by the doctor’s insurance. Patients generally have no control over who works at their hospital and are understandably upset when they find out that hospitals and doctors are covered, but other services are not.
There is no easy solution in sight. Two senators have introduced a bill to solve this problem. However, this is done by allowing payers to decide how much they pay for something. Medical professional groups say this will reduce reimbursements and result in fewer available providers and facilities.
It is expected that you will need to provide documentation for everything.
In July 2020, the Department of Justice agreed to a $16.7 million settlement for alleged fraudulent billing at a rehabilitation clinic involving a management company and 27 associated nursing homes. The company was accused of pressuring therapists to meet billable rehabilitation hour targets that fell into the “very high” category of the Resource Utilization Group (RUG) payment system, which would inevitably result in higher fees being charged.
The RUG system has been replaced by the Patient-Driven Payment Model (PDPM), but applying the new system will require some strict controls to ensure the system is not abused and nursing homes are not overpaid.
Our success in MedEx MBS is the result of nearly a decade of experience in medical billing and revenue cycle management. We will work with you to ensure you receive the highest possible reimbursement. Our transparent reporting process allows you to track KPIs at every stage of your revenue cycle. Call us today at 800-640-6409 to learn how we can free you from the complexities of rehab billing and build a more flexible practice.
Avoid Common Mistakes When Billing for Substance Abuse and Rehabilitation
Substance abuse treatment and rehabilitation have not always been covered by insurance. This supplement has proven beneficial for patients and their communities. However, the fact that these treatments are billable does not mean that they will be paid for.
Whether a facility bills private insurance or a government payer such as Medicaid, like any other medical procedure, payment requires the submission of an application. If this application form contains errors or is missing even the slightest bit of information, the provider will be denied payment.
Errors such as incorrect dates and substituted numbers can occur in any type of medical claim. Claims should be carefully reviewed before submission to ensure there are no inadvertent errors that will lead to the denial or rejection of the claim. Medical coding and billing also have aspects that are unique to substance abuse and rehabilitation. Therefore, it is important to have experienced billers and programmers who are familiar with this area.
Patient payment checks are in question.
In some cases, insurance companies will pay the patient for services instead of remitting reimbursement directly to the medical provider. This often results in the service provider not receiving reimbursement.
A very important part of dealing with these types of issues is to communicate with the patient upfront. Before treatment, you must sign a contract promising to use the money you receive from your insurance to cover the costs of the facility. It is important for the provider’s billing personnel to know which insurance companies are making direct payments to their clients so they can discuss with the patient and get their agreement that reimbursements must be paid to the facility.
Fortunately, in these cases, it is becoming increasingly rare for payments to be transferred to the patient. For an addict who has just finished treatment, a large check can easily be devastating. Not only is the treatment center not paid, but too often the patient spends the money on drugs, eventually returning to their addiction. The practice of sending insurance claims directly to people in recovery from addiction is prohibited in 27 states, which benefits both patients and providers.
Billing the wrong insurance company will result in claims being denied
It is clear that you need to bill the right insurance company, but the identity of the insurance company is not as clear-cut as you might think.
In some cases, a company may acquire another company and keep it as a separate company under the corporate umbrella, with a suffix or slightly different name. Insurance companies have also created subsidiaries to meet various state requirements under the Affordable Care Act.
For example, Blue Cross Blue Shield has a division dedicated to providing insurance in Florida, and if a claimant sends a claim to another Blue Cross Blue Shield company, the claim will be denied because the paperwork does not include the patient’s ID number.
Claimants must ensure that the correct name of the insurance company is matched with the correct contact information to make a claim.
Procedure codes must match diagnosis codes.
Each diagnosis is associated with an approved procedure, and if treatments are performed without the correct diagnosis code, the claim will be denied. The reason is that the insurance company does not consider them “medically necessary”. Coders must be aware that there are one or more approved treatments for each diagnosis and know which treatments are involved. If there is no proper match, they should ask the doctor for clarification before making a claim.
Consultations between your doctor and a specialist are paid for
There is a category of CPT codes called “Interprofessional Telephone/Internet/Electronic Medical Record Consultations” that covers claims when a primary care physician or other licensed medical professional obtains treatment advice from another physician with expertise. Specialists can speak with your doctor without seeing the patient in person, and still be charged.
The inability to pursue claims leads to lost revenue.
Substance abuse and rehabilitation facilities lose up to 25% of their potential revenue because they don’t have an effective process in place (or any at all) to collect fees. There are many reasons why claims are denied or rejected, some of which we’ve covered here, but there are many more. While most are easily preventable, medical coding systems are complex and can make billing difficult.
When a claim is returned unpaid, the insurance company/payer must provide a reason why, which can be very vague. An experienced biller must investigate the claim, determine the cause of the problem, and either correct the information or provide the necessary explanations and documentation to pay the claim. It is very difficult for in-house billers to find the time to review outstanding accounts receivable while also processing ongoing claims, resulting in millions of dollars being lost each year.