Revenue Cycle Management

AdvantEdge solutions include medical billing, certified coding, analytics,
practice management, compliance and ClientFirstTM service.

Revenue Cycle Management

AdvantEdge solutions include medical billing, certified coding, analytics, practice management, compliance and ClientFirstTM service.

If a provider received a COVID-19 accelerated or advance payment, CMS is starting to recoup any outstanding balance from the provider’s Medicare payments.    This process began on March 30, 2021, but generally starts on the one-year anniversary of when the provider received the first accelerated or advanced payment.

CMS will show the recoupment on the remittance advices issued for Medicare Part A and B claims processed after the one year anniversary of issuing the first payment.   The recoupment will appear as an adjustment in the Provider-Level Balance (PLB) section of the remittance advice.

The terms for repayment are as follows:

Provider and Supplier Assistance: For questions related to the Accelerated and Advance Payment Program, CMS has established COVID-19 hotlines at each MAC that are operational Monday – Friday to assist you with accelerated or advance payment concerns. You can contact the MAC that services your geographic area. To locate your designated MAC, see this CMS Fact Sheet or visit https://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/MAC-Website-List.

More details are available in the CMS ACCELERATED AND ADVANCE PAYMENT REPAYMENT & RECOVERY FREQUENTLY ASKED QUESTIONS.

 

Repayment and Reconciliation Terminology:

Extended Repayment Schedule (ERS) is a statutorily authorized debt installment payment schedule, which allows a provider or supplier experiencing financial hardship to pay debts over the course of three years. This can be extended to as many as five years, where certain extreme hardship criteria are met. Providers and suppliers are able to request ERSs after demand letters are issued. Providers and suppliers should contact their MAC for information on how to request an ERS.

Recoupment means the recovery by Medicare of any outstanding Medicare debt by reducing present or future Medicare payments and applying the amount withheld to the indebtedness (42 CFR 405.370). For the purposes of recovering accelerated and advance payments, recoupment means the recovery by Medicare of any outstanding Medicare accelerated and advance payment loans by reducing present or future Medicare payments and applying the amount withheld to the outstanding loan balance.

If a provider received a COVID-19 accelerated or advance payment, CMS is starting to recoup any outstanding balance from the provider’s Medicare payments. This process began on March 30, 2021, but generally starts on the one-year anniversary of when the provider received the first accelerated or advanced payment.

CMS will show the recoupment on the remittance advices issued for Medicare Part A and B claims processed after the one year anniversary of issuing the first payment. The recoupment will appear as an adjustment in the Provider-Level Balance (PLB) section of the remittance advice.

The terms for repayment are as follows:

Provider and Supplier Assistance: For questions related to the Accelerated and Advance Payment Program, CMS has established COVID-19 hotlines at each MAC that are operational Monday – Friday to assist you with accelerated or advance payment concerns. You can contact the MAC that services your geographic area. To locate your designated MAC, see this CMS Fact Sheet or visit https://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/MAC-Website-List.

More details are available in the CMS ACCELERATED AND ADVANCE PAYMENT REPAYMENT & RECOVERY
FREQUENTLY ASKED QUESTIONS.

Repayment and Reconciliation Terminology:
Extended Repayment Schedule (ERS) is a statutorily authorized debt installment payment schedule, which allows a provider or supplier experiencing financial hardship to pay debts over the course of three years. This can be extended to as many as five years, where certain extreme hardship criteria are met. Providers and suppliers are able to request ERSs after demand letters are issued. Providers and suppliers should contact their MAC for information on how to request an ERS.

Recoupment means the recovery by Medicare of any outstanding Medicare debt by reducing present or future Medicare payments and applying the amount withheld to the indebtedness (42 CFR 405.370). For the purposes of recovering accelerated and advance payments, recoupment means the recovery by Medicare of any outstanding Medicare accelerated and advance payment loans by reducing present or future Medicare payments and applying the amount withheld to the outstanding loan balance.

Since the decision was finalized to re-open special enrollment, the United States and President Biden have seen over 200,000 people sign up. With the coronavirus response bill being passed, financial assistance for premiums will become considerably more generous, allowing more middle-class households to qualify. It is predicted to see a spike in additional signups.

With only 36 states served by the federal Healthcare.go insurance market, it is estimated to see another spike in enrollment once states running their insurance website are factored in. As applications run through May 15 and a $50 million advertising budget to promote signup, President Biden hopes to see significant progress by mid-April.

The importance of continue growth in special enrollment is the drive towards a new form of Healthcare in the United States. It will be vital to look closely at what is to come after May 15 to Healthcare as a whole.

As vaccines become more and more available, CMS has released a payment allowance and effective dates cheat sheet to assist providers, states and insurers prepare to administer COVID-19 vaccines swiftly. Below is a quick overview of the CMS cheat sheet.

CPT Code – 91300

CPT Code – 0001A

CPT Code – 0002A

CPT Code – 91301

CPT Code – 0011A

CPT Code – 0012A

CPT Code – 91302

CPT Code – 0021A

CPT Code – 0022A

CPT Code – 91303

CPT Code – 0031A

For a full breakdown provided by CMS please visit cms.gov page here: https://www.cms.gov/medicare/medicare-part-b-drug-average-sales-price/covid-19-vaccines-and-monoclonal-antibodies

 

Sources: CMS

As of March 15, 2021, CMS has updated the Medicare payment rates for COVID-19 vaccine administration. The new Medicare payment rate for administering a COVID-19 vaccine will be approximately $40 to administer each vaccine dose.

For any COVID-19 vaccine administration services furnished before March 15, 2021, the Medicare payment rate for a single-dose vaccine or the final dose in a series is $28.39. ($16.94 for the first dose and $28.39 for the final dose)

To stay updated on billing codes, payment allowances, and effective dates, use CMS free resource here: https://www.cms.gov/medicare/medicare-part-b-drug-average-sales-price/covid-19-vaccines-and-monoclonal-antibodies. 

 

Sources: CMS

The Centers for Medicare & Medicaid released new information on how to bill for COVID-19 vaccine shots. Below is a breakdown of how to make sure you are billing correctly.

Billing for COVID-19
How to Submit Institutional Claims

Five shots must be administered simultaneously to use institutional claims unless the institution is an inpatient center. Below are valid types of bills for roster billing.

When it is time to submit a paper claim, first CMS-1450 (UB-04) and then submit roster form for patients (Contact your MAC for this form).

How to submit professional claim

For electronic claims, use PC ACE billing software to submit directly to your MAC. 

First, for paper claims, fill out the health insurance claim form and then submit the roster form for patients (Contact your MAC for this form).

How to submit a centralized bill

For individuals enrolls as a centralized biller, you can submit a professional claim to Novitas, not dependent on who administrated the shots, although you must operate in at least 3 MAC jurisdictions.

Sources: CMS

While COVID-19 vaccines are reportedly becoming more widely available to the general public, there’s no denying that the effects of the virus we’ve been dealing with for more than a year will continue to be felt across every industry, especially within healthcare. Calling for physicians, hospitals, and medical billing groups to fundamentally pivot their operations to deal with COVID-19. 

2021 is looking to be a year of much-needed recovery, but the full impact from COVID-19 will continue to evolve. To provide some guidance and direction on the healthcare industry for the remainder of 2021, we talked to the executive leadership team at AdvantEdge to provide insight into the impact of COVID-19 and what it means going forward. Based on thoughts provided by David Langsam, President & CEO, and Director of AdvantEdge Healthcare Solutions, below are the top 3 trends to watch out for:

1. Payer Mix

With unemployment rates skyrocketing, so did providers’ 2020 payer mix. As more payment responsibility falls to patients who went from insured to uninsured, we need to reflect and evaluate how we approach collections and patient satisfaction; it’s important to treat patients with the same client-first approach as companies do with their clients.

“The medical billing industry will need to treat patients with compassion, empathy, and a solution-based approach that enables them to meet their financial responsibility with dignity and satisfaction…When evaluating current operations to ensure the patient experience achieves these objectives, it’s important to take an in-depth look at your existing processes, vendors, and partnerships.

2. Encounter Volume

As the world continues to slowly get back to normal, look for encounter volumes to gradually increase. Even with telehealth services, almost 70% of physicians still provided fewer total visits (in-person and telehealth). It won’t be until restrictions ease, and social normalcy begins that these volumes will return to normal. If you are reassessing the capabilities and performance of your medical billing departments or vendors,

“…take a close look at billing performance from May through November, when elective surgeries were made available again, and encounter volumes were on the rise. This will help you validate that your operations or current billing partner are up to the task.” 

3. Telehealth 

Telehealth services exploded in 2020 due to advancements in technology, such as Zoom and other video conferencing platforms, and the need to continue interacting with healthcare professionals. Similar to remote work capabilities, expect telehealth services to continue to grow as patients and healthcare professionals witnessed the value of this offering. Many appointments that don’t require direct interaction, such as follow-up visits and initial consults, will continue to be leveraged by video conferencing platforms.

“As telehealth services grow, it will be more important that your staff or billing partner understand the nuances of telehealth coding and billing. Continue to have discussions with your billing department or medical billing partner on ongoing changes in telehealth, making sure you (or their) process and procedures are current.”

To learn more about medical billing and healthcare trends in 2021, we invite you to download our recent report on the state of healthcare, which provides more details on the top 3 trends and dives into topics such as remote staff, physician revenue loss, and regulations and compliance. To learn more, download our complimentary report: “Evaluating the Pandemic Impact on Medical Billing.

As COVID-19 starts to slow down, the congressional focus has shifted to permanently expanding telehealth access, with the discussion starting around payment, timing, and which flexibilities should be retained after the COVID-19 public health emergency expires. As conversations continue, we highlighted key information to help predict telehealth in 2021.

The main focus on Capitol Hill is the COVID-19 relief package, but with the temporary fee-for-service Medicare set to expire in April, we should expect more traction in late March.

The Department of Health and Human Services (HHS) has delayed the February 15th reporting deadline for Provide Relief Funding (PRF), with a new deadline to be decided. With many questions left unanswered, we outlined key information HHS has released to date.

Why is the reporting deadline delayed?
Is there anything PRF recipients need to do?
Does this affect the deadline for the second report due on July 31?
When can you expect an update?

As the $1.9 trillion COVID-19 relief package makes its way to the Senate for voting, AdvantEdge Healthcare Solutions highlighted key sections of the bill that will directly impact the healthcare industry.

Vaccines and Testing
Medicaid

As President Biden continues to reform the United States’ healthcare, Chiquita Brooks-LaSure looks to be a part of the plan. The Biden administration officially nominated Chiquita Brooks-LaSure as CMS Administrator Friday, February 19, 2021.

Chiquita Brooks-LaSure experience includes over 20 years in health policy, heading operations, such as guiding the ACA through passage and implementation. Brooks-LaSure also carries extensive knowledge and experience from her time on the Obama administration.

Brooks-LaSure will have a lot on her plate; from her past work and current positions, here is what we can expect if she received the position.

2021 CPT Medical Coding Updates:

Source: AMA

With Joe Biden set to become the 46th President of the United States, Wednesday, January 20th, the proposed $1.9 Trillion stimulus bill, The American Rescue Plan, will be a top priority for Biden and his team to finalize. We highlighted key information below.

Vaccination
Stimulus Checks
Unemployment
Small Business
Renters
Child Care Providers
Child Tax Credit
Frontline Workers
Minimum Wage

The Trump Administration has finalized their Phase 3 Provider Relief Funding (PRF) amounts that are a total of $24.5 billion, up from the original $20 billion amount, to over 70,000 providers, through the Human Resources and Services Administration (HRSA). 90% of each applicant’s reported lost revenues and net change in expenses in the first half of the 2020 year, according to HHS Secretary Alex Azar. The payment period of the funding will be from December 2020 through January 2021.

“With the Provider Relief Fund, we’ve been able to support providers hardest hit by COVID-19, including safety-net hospitals, rural providers, and nursing homes, helping ensure they can continue serving their communities during and beyond the pandemic,” states Azar.

HHS implemented versatility within the PRF program to accommodate the constantly changing landscape of the pandemic. For example, applicants that have not been given a baseline payment of 2% of yearly revenue from patient care were now eligible to do so. Also, funding was not just limited to new applicants of the program, those that were already eligible for original program funding amounts were invited to apply for additional funding for this round. Nursing home providers will be receiving an additional $1.10 billion in funding while ambulance providers will be receiving $1.48 billion.

The additional $4 billion added to the updated total of $24.5 billion in funding was added after the HHS quickly realized that the original $20 million budget would not satisfy the applicants’ submissions of lost revenues and net changes in expenses for Phase 3 of the program. The additional funding will distribute up to 88% of providers’ total reported losses. However, 35,000+ applicants will not receive additional payments because they have already received funds that are or are above this 88% or have not experienced a change in revenue or net expenses due to the pandemic.

Going forward, the PRF program will be still prioritizing ways to equip providers’ employees with PPE and expanding capacity to continually fight against Covid-19.

Customer service is an integral part of a customers’ experience and lasting reputation with the company’s brand. One does not only have to consider the one customer you are speaking with at the time, but also the next five people that will hear about his or her review afterward through word-of-mouth or an online review written about your company. That is why it is essential that customer service is considered and trained accordingly. 

It is particularly important to uphold quality customer service within the healthcare industry considering the confusing and frustrating path that is navigating their hospital bill. At AdvantEdge Healthcare Solutions, we carefully consider this through empathy and our “First Call Resolution” method. To get a deeper look into AdvantEdge’s approach to customer service, we asked some of our leading team members what their thoughts are regarding the subject: 

Barbara Lewis – Director, People Services at AdvantEdge Healthcare Solutions

Lyne Green – VP of Operations at AdvantEdge Healthcare Solutions

Laurie Krachenfels – Regional Director of Operations at AdvantEdge Healthcare Solutions

What makes AdvantEdge’s Customer Service Department work well?  What is unique about customer service departments in medical billing?

Can you provide more detail?

How do you measure and celebrate excellence?

On December 28, 2020, Congress passed a new spending bill, The Consolidated Appropriations Act of 2021, signed by President Trump, to reduce the cuts imposed by the Medicare Physicians Fee Schedule for 2021. The Act also provides new information on the temporary suspension of Medicare sequestration, surprise billing, and three-year delay of HCPCS add-on code G2211. 

Increase in Conversion Factor and Delay of Payment for HCPCS add-on code G2211  

Extension of Temporary Suspension of Medicare Sequestration

No Surprises Act

Key note: If the facility is participating and the provider is OoN, and the provider is not hospital-based, and the service is not an emergency; the OoN provider can balance bill the patient if the following notice and consent requirements are met:

[1] David Vaughn, Esq., Vaughn and Associates, LLC, Baton Rouge, LA

On December 11, 2020, the House and Senate committee announced a bipartisan agreement on surprise medical billing that will establish a fair framework to resolve payment disputes between health care providers and health insurance companies.

The bipartisan will include the following:

The agreement also includes a long-term extension of expiring public health programs, including Community Health Centers, National Health Service Corps, Teaching Health Centers, and Special Diabetes Programs.

Source: U.S. House of Representatives 

The alarming rise of COVID-19 cases disrupts elective surgeries across the US. Hospitals have canceled or rescheduled electives surgeries to prepare for potentially record-breaking COVID cases due to Thanksgiving gatherings. Many hospitals have placed strict rules on non-emergency surgeries.

While elective procedures such as knee or hip replacements are most profitable and hospitals are now better equipped to handle elective surgeries and COVID, the stress of the holiday spread and revival of the current virus causes hospitals to prepare for maximum capacity, causing a financial predicament.

The US backlog on elective surgeries is already in the millions. According to research published by The Journal of Bone & Joint Surgery and the Journal of Cataract & Refractive Surgery, there will be a backlog of more than 1 million orthopedic surgical cases after two years of elective surgery deferment. Cataract surgeries have also been backlogged to over a million. Not only causing issues to hospitals, but much of a patient’s care is dependent on elective surgeries. Generating more healthcare provider burnout, financial stress on the organization, and affecting a patient’s healthcare providers’ point of view.

Factors that need to be taken into consideration before restarting elective surgeries include making risks visible. Not being able to see possible risks can lead to increased problems. Surgical teams need to prepare for how they will safely perform the procedure, monitor the patient’s safety after the procedure, and ask patients questions before the surgery. This is to address their physical and mental health and plan for pre-and post-op care. They should not assume that patient circumstances from pre-pandemic are the same now; patients may not be able to obtain the help they need after surgery

It will be important to monitor how the US addresses the backlog of elective surgeries under new leadership in 2021.

As a new president takes office, new healthcare advisors and officials will follow. The Biden Administration is expected to adopt new policies focusing on the Affordable Care Act and Medicaid. With reform on the United States’ healthcare approaching, so is a new team to combat former health policies administered under Trump.

Biden is putting the Covid-19 at the top of his to-do list and relaying back the focus to science and research as his solution. In his approach, democrat advisors announced Biden will elect a group of new doctors to top appointee slots, according to a Washington Post report. Here is a preview of potential candidates, many of which were working under the Obama administration, that could be appointed as HHS secretary and CMS administrator.

Christen Linke Young

Young was active in the Obama administration for eight years and in the implementation of the ACA. She played other roles such as the White House’s senior policy adviser for health, principal deputy director in CMS, and the director of coverage policy in the HHS’ Office of Health Reform. Also, she is now a fellow with the USC-Brookings Schaeffer for Health Policy, conducting research focusing on health insurance coverage.

Ezekiel Emanuel

A health policy advisor in the Office of Management and Budget under the Obama administration, a generator of the ACA, and now recently a member of Biden’s COVID-19 task force, Emmanuel is surely a qualified potential appointee. He served as a health advisor to Biden’s campaign and chaired the Department of Bioethics at the National Institutes of Health for 14 years.

 Andrea Palm

Fighting through the Republican-controlled Wisconsin legislature stalling her official appointment, Palm has still managed to control the state’s rising Covid-19 cases by enacting strict lockdowns which were later overturned by the Legislature.

 Palm is Secretary-designee of Wisconsin’s health department, served as the chief of staff for HHS from 2013-2014, and worked as a senior adviser to the HHS secretary and White House policy adviser under Obama.

 Michelle Lujan Grisham

Lujan Grisham became the first Democratic woman elected governor of New Mexico in 2018 after serving three terms as a U.S. congresswoman. Nearly a quarter of the bills she sponsored focused on health, according to GovTrack, during her time in Congress.

Lujan Grisham also served as New Mexico’s secretary of health from 2004-2007. As governor, she has received praise from public health experts and Democrats for her handling of the coronavirus pandemic, with aggressive preventive measures early on.

Lujan Grisham authorized a study on implementing a public option at the state level, alongside Biden’s push for the plan nationally, according to Politico.

 Kavita Patel

Patel has upheld positions such as deputy staff director on health to the late Sen. Edward Kennedy, D-Mass., a director of policy in the White House under Obama, and took part in the senior staff of the Health, Education, Labor, and Pensions Committee.

Patel is currently a fellow at the Brookings Institution, a member of a committee advising HHS on physician-focused payment models, and an advisor to the Bipartisan Policy Center.

 Rebekah Gee

Gee was the Louisiana’s top health official from 2016 to 2020, having part in the state’s largest agency with a budget of $14 billion. While secretary, Gee also had part in the state’s Medicaid expansion, which extended the safety-net insurance coverage to more than 500,000 Louisianans.

Previously, she was the state’s Medicaid medical director and the director for the Louisiana Birth Outcomes Initiative, a statewide effort to improve birth outcomes. Currently, Gee is CEO of LSU Health New Orleans’ Health Care Services Division.

Gilead granted Louisiana a five-year license for an unlimited supply of a hepatitis C drug to treat Medicaid members and the prison population in exchange for $60 million a year under her role as Louisiana’s health chief.

 Karen Bass

As one of California’s Democratic representatives, she has supported “Medicare for All” and universal healthcare that could steer her support from the liberal wing side for her potential appointment but threaten Senate’s confirmation. Prior, she was a physician assistant before entering into her government role. Bass served as a congresswoman since 2011 and was California’s state assembly for six years. Currently, she is named leader of the Congressional Black Caucus.

Vivek Murthy

Before joining the government, Murthy was an attending physician, instructor at Brigham and Woman’s Hospital, and a surgeon general under the Obama administration. He was chairperson of the National Prevention, Health Promotion and Public Health Council. He was tapped to serve on the board of doctors advising Biden on COVID-19 earlier this year, and has already been selected as a co-chair of Biden’s official pandemic task force.

Murthy served as surgeon general during the Obama administration, and was the chairperson of the National Prevention, Health Promotion and Public Health Council. He was tapped to serve on the board of doctors advising Biden on COVID-19 earlier this year. Also, he has already been selected as a co-chair of Biden’s official pandemic task force.

 

A new update published by the American Medical Association (AMA) includes new vaccine-specific codes to report on immunizations for Covid-19.

These new codes were established by AMA working closely alongside the Centers for Disease Control and Prevention. The CPT Editorial Panel approved a CPT code unique for each of the two Coronavirus vaccines and administration codes unique for each vaccine.

The outcome of this is better tracking, reporting, and analysis that supports future planning and allocation that are backed by data.

AMA President Susan R. Bailey, M.D., states, “Correlating each coronavirus vaccine with its own unique CPT code provides analytical advantages to help track, allocate and optimize resources as an immunization program ramps up in the United States.”

The new Category I CPT codes and long descriptors for the vaccine products are as follows.

Also, the CPT Editorial Panel has worked alongside the Centers for Medicare & Medicaid Services to create new vaccine administration codes specific to the Covid-19 vaccine and the correlating specific dose in the required schedule. This will provide tracking of each vaccine code even in instances where the vaccine was given to the patient for free.

The new vaccine administration CPT codes and long descriptors are as follows.

All of the new vaccine-specific CPT codes listed in this article will be available for use and effective upon each new coronavirus vaccine receiving Emergency Use Authorization or approval from the Food and Drug Administration. The AMA website will provide the short and medium descriptors for the new vaccine-specific CPT codes to be accessed and several other recent modifications to the CPT code set that have aided the public health’s response to Covid-19.

Sources: AMA

AdvantEdge