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TO BILL OR NOT TO BILL? THAT IS THE QUESTION Presented by: Ellen M. Reynolds, MS Associate Director Cynthia Yemma, CPC, Billing/Coding Specialist Patricia.

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Presentation on theme: "TO BILL OR NOT TO BILL? THAT IS THE QUESTION Presented by: Ellen M. Reynolds, MS Associate Director Cynthia Yemma, CPC, Billing/Coding Specialist Patricia."— Presentation transcript:

1 TO BILL OR NOT TO BILL? THAT IS THE QUESTION Presented by: Ellen M. Reynolds, MS Associate Director Cynthia Yemma, CPC, Billing/Coding Specialist Patricia Parkes, RHIA, Coordinator, Health Information Management

2 Learning Objectives 1.Identify key steps in determining whether or not to bill third party insurers for services rendered in your college health setting. 2.Compare current practice within the health center to key steps for a successful billing program 3.Discuss the cost benefit analysis of potential billing program for your health center.

3 URI Health Services Overview Comprehensive Ambulatory Care Center –Services include Acute Care, Primary Care, Pharmacy, Diagnostic Lab, Diagnostic X-Ray, Health Education, Women’s Clinic, Support Staff (HIM, Billing, Insurance) –20,000+ Office Visits per year; 23,000+ prescriptions filled per year, 24,000+ Lab tests performed per year –Joint Commission Accredited (Lab & Ambulatory Care)

4 URI Health Services Overview Facts about URI –16,000 full/part-time students at URI –“Eligible” students only not faculty/staff –HS fee of $246 per semester –Students must be insured – “hard waiver” –Open Academic Year, Mon.-Fri. 8 am – 8 pm; Sat., Sun. and Holidays 10 am - 4 pm

5 To Bill or Not to Bill? Readiness Assessment –Do you have a dedicated fee? –Scope of your health center? Are the services you provide worth billing for? –Licensed provider of care to bill under? (independent practitioner vs. MD/DO) –Staffing/Support; how can you accomplish this doing it yourself or contracting with third party

6 To Bill or Not to Bill? Outsourcing your billing needs –Issues to be aware of: Costs (% of billed claims vs. % of reimbursed claims) Resources to work with billing company (electronic claim submission, denials, incorrect policy info., etc.) Contracting with third party payers, credentialing Modalities for transfer of information (electronic -vpn, encryption, or paper)

7 To Bill or Not to Bill? Paper vs. Electronic Documentation –Our recommendation is to only consider billing if you have implemented an EMR/EHR –Priority should be to have implemented an EHR, then consider billing options

8 Ready to Bill Collection of Insurance Information –Waivers and in-person collection of information Review of insurance submission to assess whom to begin contracting discussion Contact payers to begin contracting process

9 Credentialing of Providers The Council for Affordable Quality Healthcare® (CAQH) –Universal Provider Datasource (UPD) –Initial set-up requires extensive information Recertification is required every 90 days –Allows the insurance companies to query this database and credential providers –Each payer has their own credential committee that reviews new provider requests

10 About CAQH CAQH, an unprecedented nonprofit alliance of health plans and trade associations, is simplifying healthcare administration through industry initiatives that: Promote quality interactions between plans, providers and other stakeholders Reduce costs and frustrations associated with healthcare administration Facilitate administrative healthcare information exchange Encourage administrative and clinical data integration

11 Ready to Bill National Provider Identification Numbers –Application Individual Group NPI –https://nppes.cms.hhs.gov/NPPES/Welcome.do –Fee Schedule Centers for Medicare and Medicaid Services (CMS) –www.cms.gov/apps/physician-fee-schedule

12 Outpatient Facility

13 Billing Process Coding in the EHR –ICD-9 (Diagnoses Codes), ICD-10 – coming Oct International Classification of Diseases (ICD) –CPT (Transaction Codes) Current Procedural Terminology –HCPCS – (Supplies/Pharmaceuticals/DME) Healthcare Common Procedure Coding System

14 Billing Process –Treatment Sets Derm, Surgical, Ortho, Psych, Dressing, Ear, Eye, Internal Med

15 Billing Process

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17 Third Party Billing –Collection of Insurance Information –Contracting with Third Party Payers –Courtesy Billing –Electronic Billing –HCFA Billing –Medicare/Medicaid Participation

18 Billing Process Insurance Co-payment Responsibility –Collection vs. Health Service Fee –Office Visit and Procedures covered under Health Service Fee Suturing, Ear Lavage, Dressings, Casts

19 Billing Process –Patient Billing Responsible for Lab, X-Ray, Immunizations/Vaccines –Write-Off Procedure

20 Billing Process Explanation of Benefits (EOB) –Denial management –EOB review, process accordingly –Billing status change to patient responsibility –Monthly Patient Billing Direct bill to patient vs. bursar billing

21 Billing Process Sanction Policy –Consider option of sanctioning (i.e., blocking transcript, registration for next semester, block ID card access) –Monthly Statements to Patient On third month’s statement we indicate sanction of account Payment Plans

22 Billing Process Referrals Staffing Resources –Determine the priorities based on staffing resources –Consider outside billing resources if unable to staff adequately Consider cost of both options

23 Clinical Documentation Documentation must be clear, accurate, complete and timely to appropriately bill Must reflect actual services rendered Templates and care guidelines can be created to assist with clinical documentation Create templates for frequent visit types –Include prompting when important

24 Clinical Templates

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26 Clinical Documentation Federal/State Regulations on Privacy/Security –HIPAA – (Hi-Tech) allows for disclosure to third party payers if patient chooses to use your facility under TPO (treatment, payment & healthcare operations) –Minimum Necessary still applies

27 Return on Investment (ROI) Review all the steps we discussed and look at what reasonable actions necessary to begin billing process at your facility –Volume of visits –Level of visits (new/established, levels) –Cost to staff, add technology/training vs. contracting –Estimate potential revenue vs. costs

28 ROI Continued Look at annual billable visits/services Look at insurance type: –SHIP (reimbursement be at 100%) –3 rd party (depends on contract - % of charges, discounts) –Self-pay (international students) % of Bad Debt Result will be a very rough estimate of what you can hope to capture

29 To Bill or Not to Bill? Now you have to answer the question for your health center. Thank you! Questions?

30 Contact Information University of Rhode Island Health Services – – –Phone –


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