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We, at Rely On Us, provide a comprehensive model, covering a broad spectrum of services, starting from eligibility verification to projecting practice health with a wide variety of reporting tools.
Precise and upfront determination of patient responsibility for payment of services.
Reducing the burden of administrative tasks, for the practice to focus on patient care.
Compliant and accurate coding standards, reducing denials for medical necessity.
Verifying local coverage determinations for all claims prior to submission.
Maintaining 100% HIPAA compliance across all processes.
Reducing revenue loss by enhancing processes in terms of billing, coding, or administrative tasks.
Increasing profitability and improving collections by 5-15%.
Maintaining a healthy A/R days 35-40.
Maintaining a faster turnaround time of less than 24 hours, for both billing and coding services.
Monthly review of all the processes and reporting overall practice health utilizing various billing, coding, and audit reports.
The superheroes, the barbies, the cowboys, the astronauts; well, the list goes on and on. Pediatric primary care is a unique area of expertise in healthcare, dealing with infants, children, and adolescents. Pediatric care has its own unique challenges compared to adult care, mainly due to the age group of the patients ranging between birth to 21 years.
Pediatric primary care is not just the runny noses or the playtime injuries, but a very broader area of expertise covering services such as routine well child checkups, physical and psychological growth assessments, vision and hearing screenings, vaccination and immunization administrations, addressing pediatric chronic conditions and in some cases managing serious life-threatening conditions.
Billing Medicaid and other commercial payers for pediatric services is a daunting task and requires comprehensive understanding of the policies and guidelines.
Stalwart Leadership: Pain management is a specialty with intricate guidelines requiring a team of robust experience and knowledge to handle the process. The success of any process depends upon the team we create and Rely on us has such a promising team who would inevitably bring a phenomenal change in your business revenue in-flow and we have proven records that set standards for our credibility.
Transition Strategy: We have live examples with our existing clients where we had come up with exclusive strategies for a smooth transition from onshore.
Consistency: With the dynamism pain management practice runs with, we are capacitated with a stable team with low or no attrition ensuring we maintain the consistency in our deliverables.
Sustainability: Sustainability is not part of our work- It’s a guidance influence for all our work. Rely on us has a dedicated team who are trustworthy and experienced to handle huge volumes of your practice with quality outputs.
SPSDT - Early and Periodic Screening, Diagnosis and Treatment: A federally mandated program covering comprehensive and preventive health services to patients under the age of 21. As part of the EPSDT program, Medicaid requires providers to render certain mandated services for all pediatric patients depending on their age group. Understanding the program guidelines is very important for providers to participate and treat pediatric patients as part of the EPSDT.
Early: Assessment and early detection of problems, specifically in patients with low birth weight, developmental delays, learning disorders, vision, hearing or dental issues, etc.
Periodic: Performing routine checkups at appropriate age intervals such as well-child visits, assessment of immunization status.
Screening: Performing physical, mental, hearing, vision, and developmental screenings.
Diagnostic: Performing diagnostic workup as appropriate for any problems or conditions that are identified as part of routine check-ups.
Treatment: Correction and timely treatment of any healthcare concerns identified.
After-hours Care: Pediatrics is a specialty where after-hour care is a frequent scenario and physicians often oversee the opportunity of additional revenue. Understanding the CPT® codes and billing guidelines for coding after-hour services is key for any pediatrician to avoid loss of revenue.
Time Factor: Time evaluating pediatric patients is usually on the higher side compared to adult patients. As a result, documenting time plays a vital role in pediatric evaluation and management services.
Incident to Billing: Knowledge of incident to billing is very essential for a pediatrics practice. The billing is dependent on the insurance guidelines and practice regulations which differ from state to state. The practices are usually managed with non physician practitioners (NPPs) such as nurse practitioners and physician assistants. When the patients are seen by the NPPs, the claims are submitted to the insurance companies and as per Medicare; these claims get paid at 85% of the fee schedule. But many are unaware that if the encounter is supervised by the physician, the claim can be billed under the physician’s NPI which would fetch 100% of the fee schedule payment. However, there are limitations to this type of billing as it is not applicable for new patients and also when the physician is not available in the suite. There are also exceptions to this concept where in we can bill under the physician for transitional care management and chronic care coordination services.
Billing for Immunizations: Immunizations and vaccinations are common services that are rendered by the pediatric practitioners. While billing for these services, care must be taken that the practices review all the state and the insurance guidelines before submitting the claims. Since the coverage guidelines are different for both the commercials and the federal payors, we must always keep an eye on the reimbursement of these services.
Telephone Calls: Pediatric providers responding to calls for advice usually overlook the opportunity of billing services under certain circumstances. Pediatricians who provide telephonic services to patients are reimbursed for their services under special billing circumstances with the CPT® codes 99441, 99442, and 99443, depending the amount of time spent on the telephone call for addressing the patient/parent’s concerns. However, these services are paid only when the telephonic service does not lead to a related evaluation and management service within 24 hours or if the patient is seen at the immediate available appointment. Understanding the guidelines for these set of codes is important to avoid missed opportunities on additional revenue for services rendered.
Prolonged Services: Apart from billing for services using the routine E&M CPT® codes, physicians also have the opportunity to bill for additional time spent with patients for medically necessary reasons. CPT® codes 99354 to 99357 are used for additional time spent in the setting of counseling or coordination of patient care where the amount of time exceeds the usually required duration for any evaluation and management service. Knowing when to report these CPT® codes plays a vital role in getting reimbursed for the entire time spent with the patient.
Billing for Other Relevant Services: Services such as newborn care, hospital/clinic observations, standby services, attendance at delivery are some of the other services pediatric physicians render on a routine basis. Each set of these services carry their own set of guidelines. Providers may to have expert personnel to handle the billing and coding aspects for all such services to avoid claim denials.
Commonly Missed Procedures: Apart from coding/billing for evaluation and management services, pediatricians perform quite a few office based procedures. Some services such as removal of superficial foreign bodies, destruction/cauterization procedures, earwax removals are areas where providers tend to miss revenue either due to inadequate documentation or lack of proper knowledge of what can or cannot be billed.
Patient Eligibility and Coverage Determinations: Verifying patient’s eligibility and having the right set of practices in place should be of top most priority for the pediatric practices. Determination of coverage will ensure timely payments from the insurance for services rendered and avoid the headaches of collecting money from the patients for unpaid/ineligible claims. Rely On Us helps physician to stay ahead by checking the eligibility and coverage determination.
Proper usage of modifiers on claims: Modifiers are essential elements which impact billing and reimbursement of the services rendered. Incorrect usage may lead to underpayment or non-payment of the services billed. Our billers’ pre-check all the claims before submission to make sure all modifiers that are applicable are appended to the procedure codes.
The Up-coding and Down-coding risks and pitfalls: Up-coding refers to reporting higher level of codes for patients with relatively less complicated problems which may not warrant the level of services reported. Conversely, down-coding refers to reporting lower level codes for services rendered, either unknowingly or deliberately. In either of these cases, proper documentation and reporting of services must be a day to day practice to avoid the compliance risks and avoid penalties.
Bundling and unbundling: Knowledge of CPT® codes and the rules is of utmost importance for the practice to avoid denials and get the monies paid on time. Pediatric practices need to know which procedures/codes can be reported separately when performed, and what services are paid in a packaged manner. This will avoid loss of revenue and help the practice stay healthy in terms of revenues.
We would be glad to provide a comprehensive report on your practice health and help understanding areas, where the practice would need to improve processes to enhance revenue.