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May/June 2021

Revenue Cycle Management: Health Care’s Telehealth Conundrum
By Vasilios Nassiopoulos
For The Record
Vol. 33 No. 3 P. 30

Why This Rapidly Evolving Care Model May Pose Significant Reimbursement Risks in the Short Term

Telehealth’s big breakthrough moment will be remembered as 2020, when the pandemic precipitated a massive, unexpected shift in health care models. Telehealth claim lines increased nearly 3,000% between September 2019 and September 2020 as medical practices and hospitals were forced to shut clinic doors and address care continuity through remote operations.

And while the industry rapidly embraces the telehealth revolution for its ability to drive greater access to health care, many revenue integrity teams are plagued by intensifying headaches and emerging challenges on the compliance front. Regulators who were already upping their game in terms of auditing are now turning their attention to changes reflected in 2020. The Office of Inspector General’s recently announced audit plans related to COVID-19 discharges require providers to pay special attention to how they document and bill telehealth.

Because telehealth remains largely untested on the reimbursement front, sound revenue integrity practices are paramount to getting out in front of billing issues and ensuring complete capture of all appropriate revenue opportunities. Forward-thinking provider organizations are looking to the promise of technology-enabled processes and marrying them with a holistic approach to revenue integrity that draws on the strengths of both prospective and retrospective auditing.

Understanding Risk Areas
The Centers for Medicare & Medicaid Services’ decision to relax telehealth claim restrictions makes it easier than ever to get paid for remote encounters. That said, providers need to understand that there is a lack of uniformity in expectations across state lines.

Foundationally, telehealth reimbursement hinges on documentation quality. This means that until the industry has clearly tested and defined the parameters around compliance, physicians need to make sure they are documenting every part of a patient encounter, from the visit objective to the assessment and any virtual examination or evaluation that is conducted. Reviewers reading documentation should have a clear understanding of the physician’s thought process about what is being monitored, ruled out, and designated worthy of follow-up.

Revenue integrity teams should closely monitor claims that have not been adjudicated. Insurance carriers typically respond either with payment or a rejection within 30 days of submission. If the timeframe lags, the catalyst for the delay may be a variety of factors—carrier confusion over new rules, difficulty updating telehealth codes in existing software systems, or lack of bandwidth to process telehealth claims to name a few.

Whatever the reason, proactive outreach is paramount because history reflects this certainty: The older a claim gets, the less likely it will be paid at all.

Shoring Up Revenue Integrity Around Telehealth
Holistically addressing revenue integrity processes requires that all billing and compliance team members work proactively to extract the value of both prospective and retrospective auditing. Prospective audits, which take place prior to claim submission, focus on reviewing specific, targeted cases such as telehealth claims. The goal is to submit a clean, error-free claim that will pass regulatory audit tests.

In contrast, retrospective auditing involves reviewing claims postadjudication. Retrospective audits give revenue integrity teams the time needed to dive deeper into underlying problems or high-risk areas.

Monitoring and tracking the behavior of telehealth claims is important within this holistic framework. Revenue integrity teams should ask: Were they paid and at the right rate, or were they denied and why? Was the reason for any denial based on the regulations before the Centers for Medicare & Medicaid Services’ policy simplification, or was it denied because the claim was not submitted with proper codes, modifiers, etc?

Coder training is a given, but providers should also use knowledgeable HIM professionals to identify errors in physician documentation and to help educate physicians. The reality is that new ICD-10 testing and telehealth codes are creating confusion for clinicians who lack the time and resources to stay up to speed on ever-evolving guidance.

Another best practice is to increase the bandwidth within key coding and auditing departments by reassigning staff from areas where services may have less risk or are less of a priority from an auditing standpoint. For example, when elective surgeries were paused, providers were smart to strategically place employees assigned to those functions into new areas of concern. These considerations can also extend to back-end processes. Providers can make the most of limited resources by utilizing all available staff to increase bandwidth and aggressively monitor for appropriate payments or delays.

Technology’s Growing Role
As an enabler of the efficiencies to get ahead of issues, technology should be a core component of any revenue integrity strategy. The right infrastructure can help pull revenue integrity teams out of the silos in which they have traditionally operated to create a culture of collaboration around process improvement and revenue integrity excellence.

Revenue integrity processes are data hungry by nature. Therefore, manual processes that require combing through massive amounts of claim lines are not an effective use of resources. A framework of automation should support both continuous and proactive auditing (prospective) of claims before they are submitted and immediate and ongoing monitoring of delayed or denied claims (retrospective). Analytics tools can extract key charge and payment data to provide instant visibility into all prospective and retrospective data sources, eliminating the manual preparation time that often bogs down revenue integrity strategies.

Use of advanced artificial intelligence tools such as natural language processing can further elevate strategies to improve management of a health care organization’s overall financial performance. Artificial intelligence can analyze large volumes of historical data to extract important information that delivers a depth of understanding about denial attributes that is typically a nonstarter with manual processes. These systems learn from trends over time and can then, in turn, automatically apply identifiers or changes to future claims prior to submission to various payers. For example, denials related to medical necessity account for almost 10% of total denials. Identifying the root case and applying the necessary edits or process changes will greatly prevent future denials.

Telehealth: An Evolving Opportunity and Challenge
While telehealth has faced its fair share of reimbursement hurdles in past years, most experts agree that remote care models are here to stay. Patients will expect and increasingly demand these options.

The big question is how payers will process claims and reimburse going forward. There is a significant opportunity for telehealth to expand access to care and lower costs, but growing pains come in the form of interpreting complex and fluid guidance around compliance and reimbursement. Simply put, providers can expect continued changes.

When it comes to telehealth, providers are wise to get their revenue integrity house in order sooner rather than later. Those who draw on the promise of technology to help monitor and audit the health of their telehealth claims will likely be best positioned to optimize reimbursement during the current financial climate.

— Vasilios Nassiopoulos is vice president of product strategy and innovation at Hayes. A senior executive with more than 25 years of health care experience, he possesses extensive knowledge of EHR systems and practice management software.