As every healthcare executive knows, a healthy revenue cycle relies on precise paperwork. That’s why all Medicare providers should be paying close attention to the revised medical necessity form, which will be mandatory starting January 1, 2021. Failure to use the new Advance Beneficiary Notice of Non-coverage (ABN) form could lead to denied claims, financial penalties and a subpar patient experience.
We interviewed Theresa Marshall, senior director of data compliance at Experian Health, about what’s changed and what providers can do to prepare.
What is a medical necessity form?
Medicare only pays for services and procedures considered “medically necessary.” In situations where a procedure isn’t considered medically necessary, providers must issue the patient with an ABN which ultimately transfers financial responsibility to the patient.
Services that could be considered medically unnecessary might include treatment in hospital that could have been provided in a lower-cost setting, screening or therapies that are unrelated to the patient’s symptoms, or hospital stays that exceed a specified length of time. Perhaps a patient is receiving support with personal care from a home health agency – this may not be strictly medically necessary, so the provider might anticipate that it won’t be covered by Medicare. An ABN isn’t required for services that are never covered by Medicare, such as dental care or cosmetic surgery.
What’s changed on the new medical necessity form?
The new form, CMS-R-131, replaces the version released by CMS in June 2017. The main change is the addition of new instructions for Dual Eligible beneficiaries. These are patients who are eligible for both Medicare and Medicaid, and most likely enrolled in the Qualified Medicare Beneficiary Program (QMB), which means Medicaid pays for any Medicare-covered services. Providers must not levy any charges against QMB patients, or they’ll face sanctions. The new instructions specify that in addition to edits that strike through specific language, “dually eligible beneficiaries must be instructed to check Option Box 1 on the ABN for a claim to be submitted for Medicare adjudication.”
How should providers prepare?
Should they chose, providers can start using the new form now. The important thing to remember is that they must have the new form in place by the new year. Any outdated forms after the first of the year will be invalid.
Many providers are still using manual processes which require checking medical necessity rules for both Medicare and commercial payers via the CMS website, then calculating and preparing the required paperwork themselves. This can be time-consuming and vulnerable to errors, which also results in denied claims and extra days in accounts receivable (A/R) – not to mention the extra stress it causes for patients.
A time-saving alternative is an automated tool such as Experian Health’s Medical Necessity. With automation, you can validate clinical orders against payer rules quickly and accurately, for cleaner claims the first time around. Medical Necessity integrates seamlessly with multiple electronic medical records (EMR), scheduling and registration systems, to run automatic checks for medical necessity, frequency and duplication. With up to half of denied claims occurring early in the revenue cycle, any actions to minimize errors and delays during registration could bring big financial benefits.
Medical Necessity from Experian Health will include an automatic check of a Medicare beneficiary’s QMB status ahead of the January 2021 deadline, so the electronic ABN can be updated immediately, ready for the patient’s signature.
Could this improve the patient experience?
Yes, definitely. In addition to reducing manual processes, preventing denied claims and protecting against lost revenue and financial sanctions, automating medical necessity checks also creates a much less stressful experience for patients. For individuals who are financially vulnerable, any lack of clarity about their medical bills can be a huge source of worry. But when providers can quickly identify patients who shouldn’t be charged, the billing experience is a much smoother ride.
Medical Necessity is just one of the many ways that Experian is working to reduce the burden on hospital resources, improve patient experiences, and ensure that hospitals are fully compensated for the care they provide. Find out how we can help your organization get your paperwork in order in time for the new ABN requirements in January 2021, so you can offer a better patient experience and reduce claim denials at the same time.
In previous winters, anyone struck by a sore throat or fever might assume they had flu, and head to bed with a hot drink and some painkillers. This year, the looming specter of COVID-19 could prompt those with flu-like symptoms to seek medical care instead. Combined with a likely second wave of COVID-19 cases as lockdown requirements relax, healthcare organizations anticipate a surge in patients seeking tests and treatment this winter.
To protect against a possible “twindemic”, where COVID-19 and winter flu season collide, providers will want to ensure the patient intake and access process is as easy and efficient as possible—and not just for regular appointments with a primary care physician or specialist, but for pandemic- and flu-related services like COVID tests, flu shots, and more.
Online scheduling has been a game-changer during the pandemic: could it be the key to surviving a twindemic? With the right digital tools in place, providers can screen patients for their COVID-19 or flu risk before attending an in-person appointment, helping separate healthy patients from those suspected of having either illness. Providers can also leverage those same digital tools to streamline activity like flu shots, or even drive-through testing for COVID-19.
Four ways to leverage digital scheduling for a twindemic
These four steps could be key to protecting patients, streamlining workflows and reducing pressures on call centers during flu season as it collides with COVID-19:
1. Create screening questionnaires during patient scheduling
As soon as the patient logs on to book an appointment, they are asked to answer a few short questions about their symptoms. A screening questionnaire can triage people wanting to get tested, while the answers inform providers of the likelihood of a patient having COVID-19 and if that individual needs to quarantine. After being screened, the system can direct patients through the correct channel of care based on the information provided.
A similar questionnaire could be adapted during flu season for providers to assess and compare symptoms and risks ahead of time. Providers can even designate day and time slots available to patients for flu vaccinations, making it easy for patients to schedule on their own time and further minimizing the risk of unnecessary contact with other patients in office.
2. Direct patients to drive-through testing to minimize in-person tests
Depending on the answers given during screening, patients may be directed to virtual and disease-specific care, such as drive-through COVID-testing. An online scheduling platform can easily be used to book appointments for tests, presenting patients with any available time slots, either same-day or a few days out. The platform can also record information about the patient’s vehicle to quickly identify patients and avoid bottlenecks in the drive-through.
With so many patients hesitant to show for in-person visits today, a similar system for flu shots could serve providers well.
3. Use guided search to direct patients to the right virtual services
Virtual care has proven both necessary and valuable during the current pandemic. Not only has it kept patients in close contact with providers and specialists, but it has helped providers capture revenue lost from the cancellation or delay of in-person appointments.
Virtual care will be increasingly critical during a dual COVID-19/flu season. By asking the right questions during online scheduling, patients can be connected to the correct provider, whether virtual or in-person, for their needs and book an appointment quickly and easily.
4. Eliminate walk-through traffic at urgent care centers
Urgent care centers are already known to be the ‘doctor of choice’ for many patients, but this could pose a few challenges for both patients and providers during a dual pandemic. Rather than be a gathering spot for patients with both illnesses, urgent care centers may want to consider switching to an appointment-only system, where appointments must be scheduled online or by phone. This can help reduce the number of in-person visits and walk-in traffic, which will not only help keep everyone safe and healthy but contribute to a far better patient experience as patients wouldn’t have to sit and wait to be seen by a provider.
Interested in hearing more about how online scheduling could help your organization manage flu season as it collies with COVID-19?
There are a host of new, previously unimaginable tools and techniques – from analytics to robotic process automation (RPA) and artificial intelligence (AI) – available to help speed up processes and increase data accuracy. But for many life sciences organisations, these tools are either not yet fully adopted or are not being put to good use within their regulatory functions.
Adopting intelligent automation could help organisations realise disruptive benefits that are above and beyond the tangible gains of cost, quality and productivity improvements. By applying intelligent automation, companies could realistically expect to enable: the seamless distribution of product information in a variety of multimedia channels to all internal and external stakeholders; rapid and accelerated implementation of product advances that could propel continuous improvement; and advanced prediction of risks to mitigate against resource capacity constraints – which have been highlighted during COVID-19.
For many companies, it could be realistic to automate as much as half of the manual maintenance tasks currently performed, resulting in significantly different future operating models where blended roles will prevail with strategic product oversight.
“One of the most common mistakes companies make is to allow business units to carry automation initiatives in silos”
But where to begin?
Where do you begin this transformation? Start with the data. Companies need to change the way people collect, curate, interpret and apply data for regulatory submissions and improve confidence in that data. According to Accenture research, most organisations are still struggling to understand the basic ‘truth’ of the data they use and exchange with others. The Accenture Technology Vision survey found just one-third of 103 life sciences executives have high confidence in their data and validate it extensively. To improve data confidence regulatory executives should take a four-step approach to change how they:
Collect Data: Life sciences organisations should utilise cloud-based solutions with global access that facilitates one repository with a single source of truth and eliminates the use of local file sharing and servers. By integrating applications across the end-to-end value chain, they eradicate data entry duplication.
Curate Data: Regulatory specialists need to apply data standardisation and master data management to define the right granular level of data for storage. This needs to be done up front. By implementing robust data governance and management, they can maintain data quality and integrity. By ensuring traceability of data evolution, as well as end-to-end transparency of submission status and its components, they help promote confidence in the data itself.
Interpret Data: Executives need to make more use of readily available data to drive business decisions and optimise operations. They should be applying analytics to past submission data to recommend future submission content plans and pre-empt and mitigate health authority (HA) questions.
Apply Data: Regulatory employees should be using stored data to intelligently create submission documents. By limiting documents full of free text fields and subjectivity companies can adopt a more digitised approach, where document templates can be compiled automatically from available data. Making real-time data accessible to the consumers of the information when and where it’s needed increases the likelihood of buy-in to the system’s value-add. In this way, manufacturing scheduling can be optimised, and batch release decisions more informed. This, in turn, enables healthcare practitioners to get the most up-to-date product information at their fingertips.
Focusing on the business outcomes of how data can be interpreted and applied, through implementation of analytics, RPA and AI, will help strengthen your data vision, enhance your data stewardship culture and provide financial justification for investing in improved data management. This is crucial because all signs point to a future world order of increasing volumes and complexity of new products coming to market, and digital support is a must have – not a nice to have – to handle this workload.
What intelligent automation to consider?
As companies make the move into the realms of intelligent automation, there are 3 key considerations that need to be considered from the offset.
Set the North Star vision: Discuss the company strategy and pipeline considerations for the next 3-5 years and what the business objectives to achieve this strategy are. Is the driver for intelligent automation waste reduction and cost saving, or the speed at which innovative products are being brought to patients? Define the priority focus areas for your intelligent automation roadmap and evaluate the balance of ‘quick wins’ versus longer term strategy initiatives.
Create the Operational Blueprint: Outline what the future processes look like with the inclusion of intelligent automation. What activities remain and from where should they be performed? Consider how job descriptions and roles will evolve to account for the transformed future working environment.
Prototype, automate, evaluate, repeat: Establish the infrastructure to prototype at speed and fail fast. Consider how to implement in an agile, modular manner that gradually combines into an end-to-end solution. Carefully evaluate benefits realised.
“Lack of communication on how the workforce will be re-purposed post automation implementation can lead to internal unrest and possible attrition”
Here are some example use cases showing how Intelligent Automation is changing the game:
Regulatory Requirements & Content Plans
Business Challenge: Maintaining data on submission requirements is a constant challenge. As a result, market requirements gathering is often repeated for each submission, generating longer lead-times. Additionally, insights gained from HA feedback are not incorporated into submissions, reducing first time submission approval accuracy.
Solution: Analytics can compare new submission properties against past submissions to suggest a content plan based on the closest match, and most recent, approved submission.
Health Authority Correspondence Processing
Business Challenge: Timely recording of submission approval dates or tracking of HA questions can be challenging when information received by affiliates needs deciphering and translating before being entered into regulatory systems.
Solution: AI tools can translate and decipher letters without the need for local affiliate intervention and automatically enter information in Regulatory Information Management systems for stakeholders to act upon.
Label Authoring and Tracking
Business Challenge: Managing and providing traceability of the roll out of global label updates is onerous based on language nuances, implementation considerations and replicated data terms across multiple documents which can lead to a high risk of product label inconsistencies.
Solution: AI tools can take the complexity out of mapping global-to-local terms and automatically suggest what updates are needed where, as well as provide end-to-end traceability of the update progress.
As companies make the move to adopt intelligent automation, they need to make sure their projects are: business-outcome oriented (rather than simply automating a task or function); human-centred (so they don’t just eliminate repetitive tasks but rather free up people to focus on higher-value analysis, decision making and innovation); and technology rich (i.e. integrated into the broader architecture of data sources and applications).
How do you ensure success?
And there are pitfalls to avoid. One of the most common mistakes companies (across all industries) make is to allow business units to carry automation initiatives in silos. You should drive home the notion of ‘one company’ and keep an eagle-eye out for cowboys building their own rogue programmes. Similarly, make sure everyone is on the same page – if there is a disconnect between IT and the business, what’s built may not serve what’s needed. And make sure your HR, training and communications teams are looped in, informed and armed with the right information and tools to encourage and support adoption.
Lack of communication on how the workforce will be re-purposed post automation implementation can lead to internal unrest and possible attrition. There will need to be training and change control in place, and that takes planning and management. Finally, from the onset and throughout there needs to be a team tasked with ensuring responsible automation is in place. This needs to be owned by the C-Suite and at every turn communicated to employees, so it is part of the DNA of the transformation: consider the ethical and legal implications when data is handled, and tasks are automated. Know who is accountable and responsible for outcomes and ensure those teams own that responsibility.
The process of adopting intelligent automation isn’t easy but it’s also unavoidable. Adoption of processes and procedures to handle complex data is essential in this day and age – the companies that fail to build a platform that is adaptable to change are at risk of being left behind; those that do adopt new solutions are not only poised to succeed – they are the industry leaders of the future.
About the author
Kim Brownrigg is a senior principal at Accenture and leads the Regulatory Domain in Europe. Her responsibilities include interlinking Consulting, Technology and Operations services to optimise client value and defining next generation service offerings. Kim is currently leading Accenture’s Regulatory digital transformation programme; helping clients define their digital strategy and roadmap within Regulatory, designing applied intelligence solutions and prototypes and delivering pilots and scaled implementation to transform and streamline the industry.
today expect digital capabilities from their provider and will
increasingly choose those who offer digital capabilities. Knowing this,
many providers have been working to shift more of the patient journey online,
through telehealth and virtual care. Not all care needs to be delivered face to
face, and technological advances allow patients to access more services from
the comfort of their own homes, at a time that suits them.
has been visible for a few years now, as consumers sought out more smartphone-friendly
digital healthcare experiences. But change in the healthcare industry often
comes at a lumbering pace, so when the coronavirus pandemic hit and accelerated
the transition to remote care, many organizations found themselves on the back
foot. Now, it’s a case of catch-up, keep up or get left behind.
for telehealth services grows, so too does the regulatory framework around it.
A big part of staying competitive will be the ability to keep track of new
telehealth regulations and changing payer rules. Those that don’t will find
their collections straining under the added pressure of missed reimbursement
opportunities. How can providers stay on top of the changes and maximize
Keeping track of telehealth
Since early March 2020, the federal government has moved to make telehealth
more accessible to patients with Medicare coverage. Limitations on the types of
clinicians that can provide telehealth services under Medicare have been
waived, while Medicare beneficiaries in rural areas and those with audio-only
phones can now access care remotely. New telehealth services will be added to
the reimbursable list under a quicker process, which is a huge benefit to both
patients and providers, but will mean the rules around reimbursement could
change more frequently.
“These changes allow seniors to communicate
with their doctors without having to travel to a healthcare facility so that
they can limit risk of exposure and spread of this virus. Clinicians on the
frontlines will now have greater flexibility to safely treat our beneficiaries.”
Flexibility is always welcome – but what do looser rules mean for reimbursement workflows? Three challenges stand out:
Payer variation. Telehealth and telemedicine data can be presented
differently by different payers, causing a headache for providers during
Coding variation. Each type of telehealth visit is coded and billed
differently. Regardless of where appointments are carried out, clinicians must
still follow the same billing workflow, so keeping track of the differences is
Geographical variation. Providers now have to track billing and coding changes
for telehealth services from different payers across multiple states.
What can providers do to bill telehealth services as accurately
Billing for telehealth services more frequently calls
for a solution that’s flexible enough to keep pace with changing payer rules,
and sufficiently scalable to provide real-time reimbursement information when
it’s needed. Automation can help achieve both of these goals.
Two use cases for automation:
Quicker Medicare checks: Run quick and accurate checks to confirm patients are eligible for Medicare coverage for the services in question. A tool such as Coverage Discovery can comb for available coverage, even as patients are switching plans or payer rules are changing. In addition, eligibility verification automations can sweep for coverage information on telehealth services, using reliable and secure third-party data and analytics to check for updates.
Cleaner claims submissions: Tighten up billing workflows so that claims can be submitted as soon as possible. Claims management software can run automatic checks so that every claim is submitted clean and error-free. Any missing or incorrect codes can be flagged up, eliminating costly and time-consuming rework. Telehealth alerts can be included as customized edits to confirm whether virtual care is a benefit included in the patient’s current plan.
While these actions can help protect your
bottom line during the immediate crisis, they’ll also help you build a solid
foundation as your telehealth offering inevitably continues to grow. Whether
you’re looking to verify coverage, check eligibility or protect patient
identities as they log in and use telehealth services, reliable data is key.
a free consultation to discover how Experian Health can help you leverage
accurate and real-time data insights to optimize your billing workflow and
maximize telehealth reimbursements.
There’s a phenomenon in online product reviews
where the customer seems to love their purchase, yet gives it only one or two
stars. Why do they do this? Poor customer service: the item was delivered late,
questions went unanswered, or payment processing was disorganized. When the consumer
experience falls below expectations, the brand suffers – no matter how good the
The same thing happens in healthcare. The clinical
care may be outstanding, but if the patient finds billing frustrating or
confusing, it’s those feelings they’ll associate with the overall experience. Many
healthcare providers suffer reputational damage because the patient financial
experience fails to match high quality clinical care.
This is especially true for patients who find
themselves without coverage and in need of financial assistance, which is often
an extremely stressful process. And with unemployment
levels soaring as a result of the coronavirus
pandemic, it’s likely more Americans will need to explore eligibility for
charitable support. Finding smarter, speedier and scalable ways to check
charity care eligibility is even more important.
Using automation for faster charity care
Automation may be the answer. With a system
that runs checks quickly and easily against vast databases of up-to-the-minute
records, providers can discover a patient’s propensity to pay before treatment
is even carried out. Clarity from the outset ensures the patient is put on the
right payment pathway and lays the groundwork for a positive
patient financial experience.
Caye Mauney, Patient Access Director for Palo Pinto General Hospital,
tells us how her organization used data-driven financial clearance checks to improve
the patient financial experience and reduce bad debt:
Speeding up checks for earlier eligibility decisions
Prior to using automation, Palo Pinto General used a time-consuming
and labor-intensive paper-based process to determine a patient’s eligibility
for charity assistance. But with automated screening prior to or at the point
of service, the hospital can now verify whether patients qualify for charitable
assistance within three seconds, and quickly connect them to the right program.
For those with a self-pay amount, a Healthcare Financial Risk Score can be
calculated using historical payments information and credit history, to help
determine the optimal payment plan.
Mauney says: “All the information we need is now at our
fingertips. The patient no longer needs to bring in check stubs or go back to a
former employer to ask for information. It’s been a game changer.”
Creating a personalized patient experience
At Palo Pinto, staff wanted to make sure that patients were taken
care of not only medically, but financially too. Just as each patient needs
medical care tailored to their individual needs, so too should their financial
accounts be handled on a case by case basis.
With custom payment plans based on an individual’s unique
financial situation, the payment process can be transformed into an experience
that patients no longer dread or avoid.
clearance checks draw on multiple sources of data and run analytics to quickly
determine the best option for each patient. It can also generate scripts for
patient advocates to use, to help patients navigate the process more easily. Palo
Pinto reports improvements in patient satisfaction and trust as a result of uncomplicating
the patient experience in this way.
Reducing bad debt and increasing point-of-service collections
Seamlessly connecting patients to the right financial assistance
program allows patients to focus on their treatment, while feeling reassured
that their financial obligations will be met. For providers, swift processing
means decisions are made quickly, resulting in fewer accounts receivable delays
and a lower risk of uncompensated
At Palo Pinto General, quicker charity applications means more are
being approved, and therefore not written off as bad debt – ultimately helping
their bottom line.
Discover how automating checks for charity care eligibility with Patient
Financial Clearance can help your organization increase productivity,
improve collections and boost patient satisfaction.