Pulling back the Curtain: Understanding the medical billing process Shirley Reitz, PharmD Shirley.Reitz@omedarx.com August 10, 2016

Key Take Aways Medical billing is different from pharmacy billing A provider = A provider = A provider This is a new for the health plans as well Success is possible August 10, 2016

Pharmacy Claim ? Rx Switch Vendor PBM

Medical Claim ? Billing Service Clearinghouse Vendor Payer

Pharmacy Billing Cycle

Medical Billing Cycle

Collection & Verification Collect Patient Information Verify Insurance in real-time Revenue Cycle Management Obtain additional documents Obtain balance billing document Gap 1 Patient Management Need to determine insurance eligibility, schedule appointments, and collect patient information prior to or during visit

Medication Decision Making Patient Care History Examination Medication Decision Making Utilize Pharmacists’ Patient Care Process to improve patient health and outcomes Gap 2 Clinical Documentation Need to use industry standards and structured documentation templates to record, receive, and transmit information electronically

Medical Billing Cycle

Claims Submission Post Service Post Submission Post Payment Gap 3 Coding and charge entry to by collecting and verifying information Claim checking and error resolution Check the insurers “payer sheet” or “companion guide” Submit Claim Post Submission Check status daily Resolve denials Resubmit claim Post Payment Verify deposits Reconcile co-insurance and co-payments Bill patient for payments, deductible, and co-insurance Gap 3 Coding and Claims Submission Need to use industry standards to code and submit claims Gap 4 Different Adjudicator Need to understand medical necessity standards and contract requirements for each payer

Medical Billing Cycle

Medical claim process flow

Medical Claim process flow

Medical claim process flow

Medical Claims information Regence manages 80-100,000 medical claims daily 82-86% of medical claims auto-adjudicate Primary reasons for encountering edits: Payment generates (in general) within XXXX

Payment Gap 5 Payment Collection Review and determine contract limitations and restrictions Patient Follow up Provide printed copies of Billing Policy to patients Corrective actions for non-payments Collection Gap 5 Payment Collection Need to track claims, review denials, and ensure payments Need to collect payments from patients

Success to date Data from 1/1/16 – 7/27/16 2,090 claims submitted 1,184 claims for 99211 – 99215

Summary