For the Health of Your Practice Services and Approaches to ......©2018 Formativ Health, Proprietary and Confidential Services and Approaches 5 Quality of care is the number one concern

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For the Health of Your Practice

Services and Approaches to Improve Practice Profitability and Patient Care

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Anita Brazill

Take advantage of a Free, No-Obligation Revenue Cycle Analysis of Your Practice

©2018 Formativ Health, Proprietary and Confidential


Danielle Taimuty, MA, CPC, CEMC

3©2018 Formativ Health, Proprietary and Confidential

Manager of Client Success

• Danielle has been in the industry for 25+ years. Her background includes billing manager for an independent cardiology group, insurance claim adjudicator, insurance auditor and owner and founder of Medical Billing Solutions Services, Inc.

• Certified Professional Coder

• Certified Evaluation and Management Coder

The information enclosed was current at the time it was presented. Policies change frequently; links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. Formativ employees, agents, and staff make no representation, warranty, or guarantee that this compilation of this information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This presentation is a general summary that explains certain aspects of Medicare and various commercial carriers, but is not a legal document. The official program provisions are contained in the relevant laws, regulations, and rulings. Formativ has provided no guarantees and/or warranties regarding acceptance by insurance carriers, nor any likelihoods, guarantees or warranties regarding costs, time periods related to credentialing and contracting, and/or available reimbursement rates.


Learning Points

• Evaluating screenings and assessments to determine if the services would be beneficial to your patients and how you can incorporate these services into your practice. In addition, many of these screenings/assessments also meet MIPS measures.

• Prolonged Services

• Is it time to incorporate Telemedicine into your practice? Overview of which insurances in your area may already be paying for these services.

• Can Patient Access Services help you achieve improved patient care as well as increase your income?

• Revenue Cycle Management assessment - How to take advantage of a Free Revenue Cycle Management Analysis

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Services and Approaches

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Quality of care is the number one concern. Today we will show how we can help you improve patient care and how to:

• Increase Quality of care

• Increase Profitability

• Increase MIPS and Quality Scores


99483 – Cognition and Functional Assessment

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Commercial and medicare

Cognition and functional assessment using standardized instruments with development of recorded care plan for the patient

with cognitive impairment, history obtained from patient and/or caregiver, in office or other outpatient setting or home or

domiciliary or rest home

• Average Reimbursement: $238.30

• A single physician or other qualified healthcare professional should not report 99483 more than one every 180 days



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• Can bill with new or established patients but not with other E/M services

• Any Medicare beneficiary with documented cognitive impairment, of any cause, is eligible.

• Code 99483 (G0505) was developed specifically “to pay separately for the assessment and care plan creation for

beneficiaries with cognitive impairment, such as Alzheimer’s disease or dementia, at any stage of impairment”

(Fed Register 2016).

• Typically 50 minutes are spent face to face with patient and/or family or caregiver.




Eligible patients include those who:

• Present for the first time with clear cognitive impairment who need

a care plan to establish a causal diagnosis; OR

• Have an established diagnosis of a neurodegenerative or other CNS or general medical condition causing cognitive impairment of any

degree of severity, AND

• Are at risk for further cognitive decline over time, calling for periodic re-evaluation and revision of the care plan; OR

• Show evidence of cognitive, functional, and/or neurobehavioral worsening for any reason, including progression of their disease;

onset or worsening of another medical or surgical problem; acute hospitalization or emergency department use; change in their

available level of care and support; or any other circumstance likely to adversely affect the patient’s health and wellbeing.

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Eligible Providers:

• Any provider who can bill an E&M. Documentation must support Moderate-to-high level of complexity in medical decision making, as defined by E/M guidelines (incident to rules apply).

• Medical decision making includes current and likely

• progression of the disease, assessing the need for

• referral for rehabilitative, social, legal, financial, or

• community-based services, meal, transportation, and

• other personal assistance services.



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Documentation Requirements:

• Cognition-focused evaluation including a pertinent history (including family/caregiver interview when necessary) and exam

• MDM of moderate or high complexity

• Assess function such as Basic and Instrumental

Activities of Daily Living that reflect decision-

making capacity and need for help from others,

including ability to stay fed, hydrated, clean, and

safe; to recognize one’s own cognitive impairment;

to communicate meaningfully with providers; to

manage home heath needs; and to understand

medical advice



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• Use of standardized instruments to stage dementia

• Medication reconciliation and review for high-risk medications, if applicable.

• Evaluation for neuropsychiatric

and behavioral symptoms

(including depression), including

use of standardized instruments

• Evaluation of safety, including

motor vehicle operation, if

applicable



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• Identification of caregiver(s), caregiver knowledge, caregiver

needs, social supports, and willingness of caregiver to take on caregiving tasks.

• Advance care planning and addressing palliative care needs, if applicable and consistent with beneficiary

preference

• Creation of a care plan, including initial plans to address any neuro-psychiatric symptoms and referral to

community resources as needed; care plan shared with the patient and /or caregiver with initial education

and support.



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Exclusions

• 90785 (Psytx complex interactive)

• 90791 (Psych diagnostic evaluation)

• 90792 (Psych diag eval w/med srvcs)

• 96103 (Psycho testing admin by comp)

• 96120 (Neuropsych tst admin w/comp)

• 96127 (Brief emotional/behav assmt)

• 99201 – 992015 (New and Established visits)

• 99324-99337 (Domicile/r-home visits new pat)



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Exclusions

• 99341-99350 (Home visits new patient)

• 99366-99368 (Team conf w/pat by

hc prof)

• 99497 (Advncd care plan 30 min)

• 99498 (Advncd care plan addl 30 min)



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Example Instruments

• Functional Assessment Staging Test (FAST)

• Clinical Dementia Rating (CDR)

• Six Item Cognitive Impairment Test (6-CIT)

• Mini-Mental State Exam (MMSE)



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MIPS Measures to consider

• Quality ID #281 Dementia: Cognitive Assessment

• Quality ID # 288 Dementia: Caregiver Education and Support

• Quality ID #286 Dementia: Counseling Regarding Safety Concerns

• Quality ID # 282 Dementia: Functional Status Assessment

• Quality ID# 284 Dementia: Management of Neuropsychiatric Symptoms

• Quality ID# 283 Dementia: Neuropsychiatric Symptom Assessment

• Quality ID# 291 Parkinsons Disease: Cognitive Impairment or Dysfunction Assessment


Developmental Screening - 96110

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96110 – Developmental screening (eg, developmental milestone survey, speech and

language delay screen), with scoring and documentation, per standardized instrument

The primary focus of the screening described by code 96110 is the early identification of

patients who need further assessment of one or more areas of their developmental skills.

The following are some of the developmental areas the provider may assess based on

documentation of the standardized instrument:

• Receptive or expressive and pragmatic language abilities

• Cognitive areas (e.g., attention, memory, executive functions)

• Fine and gross motor skills

• Social interaction

Code 96110 may be reported whenever the screening is performed whether at specified health maintenance visits or at a

clinical encounter in which the medical provider, parent/guardian, or patient has concerns. Appropriate encounters would

include outpatient preventive medicine services, consultations, or new or established patient visits. These services may be

performed in both an inpatient and outpatient settings.*

* Per CPT Assistant, August 2015


Developmental Screening - 96110

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• May be billed only when a standardized screening tool is used and

results documented

• Parents’ Evaluation of Developmental Status (PEDS)

• Ages & Stages Questionnaire (ASQ)

• Vanderbilt Attention-deficit Disorder (ADHD)

• Modified Checklist for Autism in Toddlers

• Bayley Scales of Infant Development

• Woodcock-Johnson Tests of Cognitive Abilities (Third Edition)

• Clinical Evaluation of Language Fundamentals (Fourth Edition)

• Many carriers have a unit and/or age limit

• Not a covered Medicare Code

• E&M can be billed on the same day, append modifier -25

• Vignettes: http://www.heardalliance.org/wp-content/uploads/2011/04/Coding-Encounters-for-Developmental-

Screening-Testing.pdf

* Per CPT Assistant, August 2015

http://www.heardalliance.org/wp-content/uploads/2011/04/Coding-Encounters-for-Developmental-Screening-Testing.pdf


Depression Screening

Medicare

• G0444 - Annual depression screening, 15 minutes

• Medicare covers annual screening for adults for depression in a primary care setting, that has staff-assisted depression care supports

in place to assure accurate diagnosis, effective treatment, and follow-up.

• Copay and deductible waived

• May be billed in addition to AWV

• E&M may be billed on same day with modifier -25

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Medicare

• At a minimum level, staff-assisted depression care supports consist of clinical staff (e.g., nurse, Physician Assistant) in the primary

care office who can advise the physician of screening results and who can facilitate and coordinate referrals to mental health

treatment. More comprehensive care supports include a case manager working with the primary care physician; planned

collaborative care between the primary care provider and mental health clinicians; patient education and support for patient self-

management; plus attention to patient preferences regarding counseling, medications, and referral to mental health professionals with

or without continuing involvement by the patient’s primary care physician.

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PHQ-9 Depression screen questionnaire: http://www.phqscreeners.com/sites/g/files/g10016261/f/201412/PHQ-9_English.pdf

http://www.phqscreeners.com/sites/g/files/g10016261/f/201412/PHQ-9_English.pdf



MIPS Measures to Consider

• Quality # 371 Depression Utilization of PHQ-9 Tool

• Quality # 372 Maternal Depression Screening

• Quality #134 Preventive Care and Screening for Clinical Depression and Follow-up plan

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PATIENT HEALTH QUESTIONNAIRE-9(PHQ-9)

Over the last 2 weeks, how often have you been botheredby any of the following problems?(Use to indicate your answer) Not at all

Several days

More than

half the days

Nearlyevery day

1. Little interest or pleasure in doing things 0 1 2 3



Commercial

• 96127 - Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale),

with scoring and documentation, per standardized instrument

• This assessment serves as a mechanism to identify emotional and behavioral conditions that previously may have been

underestimated and/or undetected in any age population, such as depression screening and attention-deficit/hyperactivity disorder

rating scales.

• Most carriers will cover 2 to 4 units per day.

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96110 vs. 96127

Examples of instruments

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Instrument Abbreviation CPT Code

Ages and stages Questionnaire – Third Edition ASQ 96110

Ages and stages Questionnaire: Social-Emotional ASQ:SE 96127

Australian Scale for Asperger's Syndrome ASAS 96127

Beck Youth Inventories – Second Edition BYI-II 96127

Behavior Assessment Scale for Children – Second Edition BASC-2 96127

Behavioral Rating Inventory of Executive Function BRIEF 96127

Connor’s Rating Scale (No abbreviation) 96127

Modified Checklist for Autism in Toddlers M-CHAT 96110

Patient Health Questionnaire PHQ-2 or PHQ-9 96127

Parent’s Evaluation of Developmental Status PEDS 96110

Pediatric Symptom Checklist PSC 96127

Screen for Child Anxiety Related Disorders SCARED 96127

Vanderbilt Rating Scales (No abbreviation) 96127


Administration of Patient-focused Health Risk Assessment

Medicare and commercial

• 96160 Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring

and documentation, per standardized instrument

• May be billed for each instrument used

• Example instruments –

• Acute Concussion Evaluation (ACE)

• CRAFFT Screening Interview (Adolescent Sub Abuse)

• SOAPP-R (opioid risk)

• Fall Risk Assessment Tool (FRAT)

• Does not include interpretation or diagnosis

• Includes Scoring and documentation

• Typically completed by a non-physician clinical staff member (under direct supervision)

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Administration of Caregiver-focused Health Risk Assessment

• 96161 Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized Instrument

• Edinburgh Postnatal Depression Scale

• Depression scale for Elderly

• Fall Risk Assessment Tool (FRAT)

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Health Risk Assessments (96160 – 96161)

MIPS Measures to consider:

• Quality #414 Evaluation or Interview of Opioid Misuse

• Quality #154 Falls: Risk Assessment

• Quality ID# 318 Falls: Screening for Future Fall Risk

• Quality ID# 358 Patient-Centered Surgical Risk Assessment and Communication

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Prolonged Clinical Staff Service – Direct Patient Contact

• 99415: Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management

service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in

addition to code for outpatient Evaluation and Management service) and

• 99416: each additional 30 minutes (List

separately in addition to code for prolonged

service) (Use 99416 in conjunction with 99415)

• Prolonged services “clock” starts after the

typical time for the E/M

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Prolonged Clinical Staff Service – Direct Patient Contact

• Codes 99415, 99416 are used when a prolonged evaluation and management (E/M) service is provided in the office or outpatient setting that involves prolonged clinical staff face-to-face time beyond the typical face-to-face time of the E/M service.

• The physician or qualified health professional is present to provide direct supervision of the clinic staff.

• Codes 99415, 99416 may be reported for no more than two simultaneous patients. The use of the time-based add-on codes requires that the primary E/M service has a typical or specified time published in the CPT code set.

• For prolonged services by the physician or qualified health care professional, use 99354, 99355. Do not report 99415 or 99416 with 99354 or 99355.

• Facilities may not report 99415, 99416.

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Prolonged Clinician Services – Direct Patient Contact

• 99354 - Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the

primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first

hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy

service)

• 99355 - Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the

primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; each

additional 30 minutes (List separately in addition to code for prolonged service)

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Prolonged Clinician Services – Direct Patient Contact

• Codes 99354-99355 are used to report the total duration of face-to-face time spent by a physician or other qualified

health care professional on a given date providing prolonged service in the office or other outpatient setting, even if the

time spent by the physician or other qualified health care professional on that date is not continuous.

• Either code should be used only once per date, even if the time spent by the physician or other qualified health care

professional is not continuous on that date.

• Prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work

involved is included in the total work of the evaluation and management or psychotherapy codes.

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Prolonged Service Table

Table A: Office/Outpatient Setting

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Code Typical E/MTime

Threshold Time to Bill 99354

Threshold Time to Bill 99354 & 99355

Code Typical E/MTime

Threshold Time to Bill 99354

Threshold Time to Bill 99354 & 99355

99201 10 40 85 99326 45 75 120

99202 20 50 95 99327 60 90 135

99203 30 60 105 99328 75 105 150

99204 45 75 120 99334 15 45 90

99205 60 90 135 99335 25 55 100

99212 10 40 85 99336 40 70 115

99213 15 45 90 99337 60 90 135

99214 25 55 100 99341 20 50 95

99215 40 70 115 99342 30 60 105

99241 15 45 90 99343 45 75 120

99242 30 60 105 99344 60 90 135

99243 40 70 115 99345 75 105 150

99244 60 90 135 99347 15 45 90

99245 80 110 155 99348 25 55 100

99324 20 50 95 99349 40 70 115

99325 30 60 105 99350 60 90 135


Prolonged Clinician Services – Without Direct Contact

• 99358 – Prolonged E/M service before and/or after

direct patient care, first hour

• 99359 - Prolonged E/M service before and/or after

direct patient care, each additional 30 minutes (listed

separately in addition to CPT 99358)

• Cannot be reported during the same service period as

complex Chronic Care Management (CCM)

services (99487 and 99489) or transitional care

management services (99487, 99489, 99495 and

99496)

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Total Duration of prolonged Service w/o Patient

Code(s)

Less than 30 minutes Not Reported

30-74 minutes 99358

75-104 minutes 99558, 99359

105-134 minutes 99358, 99359x2

135-164 minutes 99358, 99359x3

Start & Stop Time Must Be Ongoing Care


Prolonged Clinician Services – Without Direct Contact

• Codes 99358 and 99359 are used when a prolonged service is provided that is neither face-to-face time in the office or outpatient setting, nor additional unit/floor time in the hospital or nursing facility setting during the same session of an evaluation and management service and is beyond the usual physician or other qualified health care professional service time.

• This service is to be reported in relation to other physician or other qualified health care professional services, includingevaluation and management services at any level. This prolonged service may be reported on a different date than the primary service to which it is related. For example, extensive record review may relate to a previous evaluation and management service performed earlier and commences upon receipt of past records. However, it must relate to a service or patient where (face-to-face) patient care has occurred or will occur and relate to ongoing patient management.

• Prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved is included in the total work of the evaluation and management or psychotherapy codes.

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Telemedicine

• “While only 31 states and the District of Columbia mandate that private payers cover telehealth visits as they reimburse for

in-person visits, health plans will negotiate policies with providers that include coverage for digital health services if they

can be convinced that the service improves clinical outcomes and reduces wasteful spending”

• Telemedicine is gaining momentum

• Telemedicine coverage and reimbursement vary greatly from state to state and Carrier Plans.

• ATA 110 – Page telemedicine coverage and reimbursement report

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TeleMedicine

Billing TeleMedicine

• Research the carrier requirements

• Generally you will bill the CPT code that you would have used in the office. But some carries may require you bill the 99444 - Non-Face-to-Face On-Line Medical Evaluation.

• Some carriers still accept modifier GT (via interactive audio and video telecommunications systems) or GQ (via an asynchronous telecommunications system), but Medicare has eliminated this code

• Place of service on the claim should be listed as 02 - The location where health services and health related services are provided or received, through a telecommunication system.

HIPAA compliant Platforms

• Most carriers will require the you use a HIPAA compliant platform to perform telehealth services.

• Contact your EHR vendor to see if they offer this service.

• List of some popular telemedicine apps

• Mend

• AnywhereCare

• TeleDoc

• Secure Telehealth

• Doxy.me

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Telemedicine in Pennsylvania

PA Legislature Introduces telemedicine bill

• June 2017 - A bill introduced in the Pennsylvania State Senate aims to make telemedicine reimbursement equivalent to in-person care services.

Senate Bill 780

• Senator Elder Vogel (R-Beaver) introduced Senate Bill 780 to define key components of telemedicine, set telemedicine licensing requirements and require that healthcare payers provide reimbursement for telemedicine services if they pay for the same service in person.

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Read the bill here: http://www.legis.state.pa.us/CFDOCS/Legis/PN/Public/btCheck.cfm?txtType=PDF&sessYr=2017&sessInd=0&billBody=S&billTyp=B&billNbr=0780&pn=1001

http://www.legis.state.pa.us/CFDOCS/Legis/PN/Public/btCheck.cfm?txtType=HTM&sessYr=2017&sessInd=0&billBody=S&billTyp=B&billNbr=0780&pn=1001

http://www.legis.state.pa.us/CFDOCS/Legis/PN/Public/btCheck.cfm?txtType=PDF&sessYr=2017&sessInd=0&billBody=S&billTyp=B&billNbr=0780&pn=1001


TeleMedicine – 99091

• 99091 - Collection and interpretation of physiologic data (eg, ECG, blood pressure, glucose monitoring) digitally stored

and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by

education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time

• CMS has un-bundled CPT code 99091.

• Providers must obtain an ABN (Advanced Beneficiary Notice) for this service and document this consent in the patient’s medical

record

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TeleMedicine - 99091

• For new patients or those not seen within one year before the provision of remote monitoring services, providers must

initiate these services in a face-to-face visit, such as an annual wellness visit or physical.

• Providers can use 99091 no more than once in a 30-day period per patient.

• The code includes time spent accessing the data, reviewing or interpreting the data, and any necessary modifications to

the care plan that result, include communication with the patient and/or her caregiver and any associated documentation.

• This code is not subjected to any of the restrictions on originating sites or technology that telehealth services are subject

to by statute, allowing users of this technology more flexibility.

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Highmark Blue Shield

Virtual PCP Visits and Virtual Retail Clinic Visits

• Highmark participating primary care providers who have the required telecommunications technology to support Virtual PCP Visits and Virtual Retail Clinic Visits may participate. The services performed must fall under the scope of the provider ’s license, and the sessions must be conducted following Highmark’s service and security guidelines.

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• Highmark has even created a flyer you can send out to your patients https://www.highmark.com/health/pdfs/hbsom-chapter3-unit7.pdf



Virtual PCP Visits and Virtual Retail Clinic Visits – Technology Requirements

• The Virtual PCP Visits and Virtual Retail Clinic Visits must take place via real-time audio and video telecommunications. Interactive telecommunications technology must be multi-media communication that, at a minimum, includes audio and video equipment permitting real-time consultation among the patient location and provider location.

• The provider must ensure that the aesthetic quality of the consultation is comparable to that of an in-person consultation (i.e., proper lighting, camera positioning, network connection, etc.). The provider’s monitor resolution (matrix) must be a minimum of 512 X 512 at 8-bit pixel depth.

• The technology needed by the member will be driven by the technology platform that the provider uses to conduct this service.Members can be at any location that they choose that is conducive for Virtual PCP Visits and Virtual Retail Clinic Visits, provided the member has access to both audio and video streaming technology. The member should be in a location that is private and away from other people.

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Virtual PCP Visits and Virtual Retail Clinic Visits – Technology Requirements

• Virtual PCP Visits and Virtual Retail Clinic Visits must be conducted through realtime interactive audio and video telecommunications

hardware and software that are HIPAA (Health Insurance Portability and Accountability Act) and HITECH (Health Information

Technology for Economic and Clinical Health Act) compliant.

• Highmark supports the highest standards to protect the confidentiality of our members’ information but there may be risks in passing

personal health information (PHI) virtually. Highmark is not responsible for the security of virtual visits, and does not validate the

safeguards of any equipment and software used on either side of the virtual transmission.

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Billing Telemedicine

• When billing professional services (1500/837P), Virtual PCP Visits and Virtual Retail Clinic Visits should be billed with outpatient

Evaluation & Management (E&M) CPT codes (99201-99215) applicable to the services provided and with a GT modifier indicating the

use of interactive audio and video telecommunications technology.

• Place of service should be 02 - “The location where health services and health related services are provided or received, through

telecommunication technology.” CMS eliminated the GT Modifier for telehealth services effective January 1, 2018.

• Update your PCP profile on the provider directory for virtual services.

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Other Insurances

Telemedicine

• It is essential that you call for a verification of benefits prior to rendering services.

• UPMC – You must apply to become a Telemedicine provider: https://secure.upmc.com/telemedicineservicesform/

• Aetna - Coverage varies depending on the policy. Call for coverage.

• United Healthcare - Coverage varies depending on the policy. Call for coverage.

• Medicare – Patient must live in a rural area and be located at one of these places: Doctor’s office, hospital, critical access hospital,

rural health clinic, FQHC, hospital based dialysis facility, skilled nursing facility or a community mental health center.

https://www.medicare.gov/coverage/telehealth.html

• PA Medicaid – Consultations with specialist initiated during the course of an office visit.

http://www.dhs.pa.gov/cs/groups/webcontent/documents/bulletin_admin/d_005993.pdf

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https://secure.upmc.com/telemedicineservicesform/

https://www.medicare.gov/coverage/telehealth.html

http://www.dhs.pa.gov/cs/groups/webcontent/documents/bulletin_admin/d_005993.pdf


Revenue Cycle Management Assessment

Formativ Health’s RCM Assessment is a quick way to better understand what revenue opportunities exist in your practice.

The objective of a Formativ Health’s Ambulatory Assessment is to determine:

• Financial Opportunity which may exist in the Ambulatory Revenue Cycle

• Increase in recurring net revenue

• Increase in one time cash opportunity

• Reduce cost to collect

• Challenges and barriers to achieve identified Financial Opportunities

The scope of Revenue Cycle Ambulatory assessment will include a review of:

• Front-End: Registration, Insurance Verification, Authorization Management, Charge Capture / Charge Lag

• Middle: Coding, EDI/Billing, Initial edits

• Back-End: Denials management, Insurance account follow-up, Patient collections

• Productivity metrics and financial opportunity metrics

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Revenue Cycle Management Data Request

Physician Enterprise / Ambulatory OperationsClient

Responsibility Completed

Revenue Cycle Related Information (Last 2 fiscal years, unless indicated below) q

1Monthly Management Reports, preferably by service line/specialty and payer, including:

q

Charges q

Payments q

Adjustments q

Aged accounts receivable (30 day intervals up to > 365 days) q

Co-Pay and/or time of service patient collection reports q

Bill Hold amount by reason (charges) q

Charge Lag report, with breakout by service type (office, outpatient, surgery, etc.) - will validate during account sampling and/or data validation

q

2 CPT code frequency q

3 RVUs (work and total) - can include with CPT frequency report if able q

4 Write-offs by reason code q

5 Initial denial report, with detailed reason code q

6Charges from prior fiscal year end (at least 6 months ago) with payments and

adjustments posted to those charges (sometimes referred to as a "waterfall" report or "matched" ATB)

q

7Fee Schedule/charge master for current fiscal year and prior three fiscal years

q

8Contracted payor plans and copies of agreements for each, at least top 10-15 by charge volume (can be reviewed on site if necessary)

q

9All productivity reports currently being used to monitor RCM staff productivity

q

10Any master tables and/or data field definitions that will help us map the reports provided (can be addressed during data validation)

q

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Physician Enterprise / Ambulatory Operations Client

Responsibility Completed

Forms (Can be reviewed during onsite visits) q

11 Insurance Eligibility and Benefits Verification q

12Charge Capture Forms (e.g., Encounter sheet, charge ticket, lab ticket) –please include a copy for office services and hospital services

q

13 Provider Documentation Forms q

14 Patient Collection Letters q

15 Insurance Follow-up Letters q

Other q

16Employee census or equivalent to account for all staff in CBO, central call center and/or practices focused on RCM (front-end, middle and back-end)

q

17 RCM Turnover (focused on front-end, middle and back-end Revenue Cycle) q

18 Vacancy report to show approved, but unfilled, positions in RCM q

19Vendor/Contractor report for any temporary/contract workers being used in RCM

q

20 List of third party vendors used and associated fees with each q

21Any other cost center / Profit & Loss Statements which will allow us to account for all costs related to RCM (cost to collect analysis) - 2 fiscal years

q

22 Organizational chart for practices, CBO and central call center q

23All policies and procedures, with particular focus on: q

Financial Clearance / Counseling q

Payment Variance / Compliance q

Charge / fee ticket reconciliation q

Daily cash deposits and reconciliation q

24 Detailed description of your payer enrollment process q

General Background and Enterprise Related Data q

25 Summary overview of current physician and allied health provider composition of , practice sites, professional and ancillary services by location.

q


Patient-Centered Access Services

Services and benefits

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Inbound Phone Calls

Patient Outreach

Care Coordination

• Appointment Scheduling – Support primary and specialty care practices, insurance products, and community referrals

• Registration – Occurs at the time an appointment is scheduled

• Insurance Verification - Verify patient's coverage is active and also provides basic benefits. Verify specific benefits with the carrier per CPT code

• Authorizations – Contacting insurance companies, providing clinical data and obtaining a pre-authorization for services

• Non-Appointment Assistance, such as patient requests (e.g., medication refills, results, records, directions) in coordination with the office

• Financial Counseling – Leverages dedicated support team to help identify financial payment arrangement solutions for uninsured patients and or patients receiving non covered services

• Referrals – Outbound calls to existing patients of the medical group, where a provider has written a referral order for a specialist, and for affiliated physicians utilizing EHR

• Post Discharge – Post-ED, Discharge, and Urgent Care Appointments, Direct appointment scheduling from these settings

• Population Health – Eliminate disparities in preventative care access by placing outbound calls to patients with gaps

• Chronic care management – schedule follow up to improve clinical outcomes and reduce healthcare costs


Optimizing administrative workflow and provider scheduling templates to improve patient satisfaction and increase in revenue

• Eliminate long hold times and hang ups

• Alleviate front-desk backlog

• Streamline workflow

• Improve patient communication

• Collection of patient data

• Reduce staffing costs

• Boost co-pay collection

• Efficiently schedule appointments

• Optimizing clinicians time

What is the Advantage?

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Appointment scheduling

Registration

Insurance Verification

Referrals and Authorizations

Patient financial responsibility

Additional Calls – medication refills, lab & test results, medical records, directions

Patient Outreach – Post Hospital Discharge / Post ED Visit / Urgent Care Discharge Appointments, Waitlists, Marketing Campaigns

Care Coordination – population health, episode of care, or chronic care management

100’s of patients calls

Patient-Centered Access call center

handles all inbound calls and outbound

calls associated with scheduling process

Warm transfer to practice for clinical questions and payment

arranges

Clinical and back office revenue questions


About Formativ Health

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We are redefining the ambulatory patient and provider experience throughout the health care ecosystem

Our purpose

To transform the patient and provider experience and make health care better for both.

Our approach

We partner with physician practices, hospitals, and health systems to improve financial health, enhance the patient experience, and free up physicians to focus on what they do best – taking care of patients.

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What Makes Us Different?

By Physicians, For PhysiciansWe are purpose-built by physicians with two decades of experience leading one of the largest health systems in the United States.

Comprehensive Patient Services We offer the most comprehensive, high-touch patient services in the ambulatory market, easing the patient’s clinical and financial journey, building patient loyalty and enabling physicians to focus on patient care.

End-to-End Technology Enabled ServicesOur services are the first to span the care continuum, from patient access through collections and beyond. We offer a portfolio of solutions that can be implemented in either modules or as an end-to-end solution, based on the provider’s needs.

Agnostic TechnologyOur services are able to work with the provider’s existing technology and do not require system replacements that create operational disruptions.

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End-to-End Revenue Cycle Technology and Services

Redefining revenue cycle management with tailored solutions that span the care continuum

Outsourcing

• Full and partial revenue cycle services outsourcing

• Agnostic Technology

• Portfolio of agnostic technology across front, middle, back of

revenue cycle

Analytics

• Analytics that leverage data to reveal strategic insights and

empower data-driven decision making

Advisory Services

• Advisory services that improve processes, increase efficiencies

and streamline operations

Education Services

• Education services that improve staff performance and

retention

Our Capabilities

High-Touch Patient Access Enhancing the patient, staff, and physician

experience while improving financial outcomes

High Touch Patient Access Center • Handle all inbound and outbound calls • Optimize administrative workflow and scheduling

Call Management• Answer all patient calls, direct “clinical calls” to a

centralized nursing group • Scheduling, insurance verification, registration, referral

management, requests

Care Coordination • Schedule post discharge care, disease and chronic care

management, overdue routine appointments • Identify gaps in care

Revenue Improvement • Manage appointment wait list, no shows, cancellations • Counsel patients on payment options, financial support

services

Quality Assurance • Record 100% calls; screen capture 20% • Review agents twice yearly; ongoing peer review and

management reviews • Generate scorecard to analyze each agent call

Staff Competency • Low attrition with existing staff • Targeting bachelor’s degree candidates • 8-week training program

Workforce Optimization • Predictive modeling for staffing based on day of week,

weather patterns, geography, type of practice, utilization rates, gaps in services/specialists needed, operational gaps

Practice Operations Managing administrative functions so that

physicians can focus on patient care

Personnel

• Accounting, human resources, benefits management,

research & benchmarking, practice governance

IT and Infrastructure

• Server maintenance, network management, EHR & PM

systems, helpdesk, data conversion, document

management, scanning

• Hosted cloud services, system level monitoring

Group Purchasing

• Group purchasing management, contracting for supplies

and pharmaceuticals

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Thank you

Questions

Thank you for joining Formativ Health

1.866.725.2855

www.formativhealth.com

© Formativ Health 2018

All Rights Reserved

No part of this presentation or any of its contents may be reproduced, copied, modified or adapted, without the prior written consent unless otherwise indicated for stand-alone materials.

Contact Danielle Taimuty with any additional [email protected]

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