Revenue Cycle Management in Managed Care

Unleash the power of Revenue Cycle Management (RCM) in managed care. Master the nuances of coding, billing, and auditing for Medicare Advantage. Stay ahead with compliance, technology, and strategic adaptations for success.

Recently I was interviewed by a national organization for coders and billers about Revenue Cycle Management (RCM) in managed care, specifically Medicare Advantage. And I suddenly realized that most coders have not mastered the nuances of RCM in this field. How is it that some of the most populous counties in the country have more than 80% saturation with Medicare Advantage, and its penetration is only steadily growing in the rest of the US? The experts who deal with one of the most critical processes are unaware of its specific requirements, demands, and features.

And as I delved deeper, I realized that it is critical for the success of doctors and organizations to master the challenging steps involved in coding, billing, and auditing for primary care practices or managed service organizations (MSOs) to make the doctors and their organizations successful – for example, the Current Procedural Terminology (CPT)and the International Classification of Diseases (ICD) codes change on an annual basis. All organizations must check the changes as they are announced so that the providers and the billing entities use accurate info when they code and bill – this is the simplest of the many steps to get on top of the revenue cycle. But in addition to this, there is a mindset and paradigm shift that must be understood and adapted to as well. 

The shift from fee for service (FFS) with its attendant requirements of ensuring that money is collected for every claim appropriately, and compliantly to fee for value (FFV) where we report the overall illness of the patient to the health plan and thence, the Center for Medicare and Medicaid Services (CMS) – is the first step. Just like every claim is followed in FFS to ensure that each one is paid for and not denied by insurance companies or payers, we must track every claim in FFV to ensure that the HCC codes are received by CMS so that the MRA scores are appropriately adjusted and paid for. 

The shift from Risk Adjustment Processing Systems (RAPS) to Encounter Data Processing Systems (EDPS) has not been adapted to even now by several health plans and billing entities. The old manner of submitting Hierarchical Condition Category codes (HCCs) is gone. And if one has not adapted to EDPS by now, one has risked losing significant revenues and compensation for one’s work.

The first issue is the alignment of incentives. Many billing companies are still paid a certain percentage of collections on FFS and are paid a fixed amount  – say a dollar and twenty-five cents – per claim for FFV. Thus, there is no incentive for the billing company to ensure that they collect all the money on FFV claims. The billing company must ensure they can send more than four HHC codes for each visit, even as many as 16 or 20 codes if needed. They also must ensure they have promptly transmitted all patient encounters with the primary care doctor that year to the health plan. And all the rejections at the level of the clearing house, the health plan, or CMS are followed, and to do re-billing so there is no leakage. Leakage may happen inadvertently and might be as high as 10-15 percent even after all the codes have been submitted correctly and as required.

We have found the CMS denies HCC codes sent for wellness visits. And that some TPAs do not bill for psychiatry or podiatry codes or services. These can cause significant losses to health plans, providers, and MSOs. 

It seems to me that the first step for any RCM organization in the FFV space would be to master EDPS, create systems to track big data and gaps and ensure that those gaps are either resubmitted for billing to the health plans or confirmed to be received by CMS and paid for. In addition to mastering EDPS, it is crucial for a primary medical office to either adequately compensate the billing entity responsible for performing this challenging task or develop the expertise in-house within the medical office or their MSO, ensuring that HCC leakage does not occur even after the doctor has compliantly documented the conditions. 

The second step would be to master Premium Billing and the relevant changes in funding per patient – this might be more challenging and sophisticated but eventually possible if one involves the best consultants or experts in this area.

RCM organizations need to learn to work closely with compliance and Clinical Documentation Instructors (CDIs) so that any chronic persistent conditions are re-documented, patients are scheduled for visits every semester, and new symptoms or suspects are brought to the attention of the doctor on time, before the patient visit, ensuring the condition is documented and thoroughly addressed. 

RCM for FFV is a priority for all aspiring billing and coding organizations. Technology for big data might need to be refined and developed or in-sourced. Operations need to be re-engineered. Education and constant training of the team is a sine qua non. And dashboards, interfaces, and algorithms are procured or developed and provided to the teams so that data is shared transparently, on a real-time basis, and in a simple manner to all the physicians, administrators, medical assistants, and RCM teams to ensure immediate response and adaptation.

In the blogs to follow, I hope to develop a systematic treatment of each aspect of RCM in Managed Care and create an educational cheat sheet so that more and more organizations are up to date with the new requirements of fee for value.

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