As we start a new year, we're taking a quick moment to reflect and embrace the challenges and possibilities that the upcoming year holds. Healthcare is always evolving, and this year will be no exception. With new regulations on the horizon, we're here to help you stay ahead of the curve, and are committed to providing the best solutions and support to help your organization thrive.
In 2023, we helped many of our clients through several record audits, and we believe that this trend will continue in 2024. Payers including Aetna, Anthem, Cigna, United Healthcare and MHN required both our in and out of network facilities to turn in medical records for review. After successfully completing eight insurance audits last year, here are the most valuable things we learned:
1. TREATMENT PLANS: Insurers want to see a goal oriented, actionable treatment plan that is updated with signatures from the client and provider in a timely manner. Objective goals should be set, and dates adhered to. If the client hasn’t met their treatment goal(s) by the date that was initially set, the treatment plan should be updated accordingly. Treatment plans should be detailed and specific to each client and their treatment goals. These items were a main focus for insurers, specifically for Anthem’s pre-payment review.
2. ASAM LEVEL OF CARE TOOL: ASAM (American Society of Addiction Medicine) criteria continues to be the most common set of guidelines that payers and case managers use to determine what level of care a client should be in, and auditors expect to find ASAM criteria documented in the client’s chart. Some providers have a separate ASAM level of care form, while others incorporate it in their biopsych social or other intake documents. ASAM should also be addressed any time a client steps down or changes his/her level of care.
3. WEEKLY HOUR REQUIREMENTS: Many of our providers prefer us to submit claims one day at a time. This can be helpful in keeping track of reimbursement rates and can even speed up a claim’s processing time. However, when your practice or facility is placed on an audit that requires a certain number of hours per week, we suggest switching to a weekly billing protocol – at least until the audit is complete. Most insurance companies require that providers send a separate record package for each claim. It is much more efficient to send one package for the week than it is to send seven individual packages. Another thing to note is that even though only one day may be billed on the claim, the auditor wants to see that the client is meeting daily AND weekly hour requirements.
4. PATIENT COLLECTIONS: Last year, we saw both United Behavioral Health and Evernorth (Cigna), asking for proof that our out of network facilities collected patient deductibles, coinsurance, and copays. Although there were documented attempts to collect from clients, the attempts were deemed “insufficient” by the payers. Both Cigna and United took this one step further by requesting money back in the amount of patient responsibility.
Patient Liability and Collections
Insurance audits are certainly one reason to focus on patient collections, but the changing structure of most insurance policies adds to the importance. Deductibles are higher than ever before, specifically for patients who want to use out of network providers. Coinsurance splits are more balanced, leaving higher responsibility to the patient. It has even become common to see an “unlimited” out of pocket max for some out of network policies.
By implementing an effective patient collection plan, you are guaranteed to see improvements in your bottom line, and perhaps to your surprise, with patient satisfaction. Patients appreciate transparency, and your bottom line will thank you.
As we move into a new year, we recommend that your practice or facility evaluate its charting practices. Not sure where to start? Follow the 5 steps outlined below:
Identify your most common procedures and review the CMS guidelines. Guidelines may change slightly each year so it is helpful to stay current.
Schedule a meeting with your clinical staff to explain the importance of charting for insurance and the possible financial strain that improper charting could have on your facility.
Set deadlines to complete the notes, including signatures from the appropriate staff members.
Perform weekly chart audits. We recommend auditing one chart per therapist per month.
Schedule regular trainings with your staff to review the findings of the audit.
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Efficient and comprehensive charting is essential not only for auditing purposes but also for successfully navigating the insurance authorization process. As insurance companies increasingly adopt fax-in authorizations, it is important for healthcare providers to align their charting practices with the evolving requirements.
The shift towards a fax-in method emphasizes the need for clear, detailed, and organized documentation to support authorization requests. This involves submitting relevant patient information, medical histories, and treatment plans through the designated fax channels. Failure to comply with chart upload requirements may result in delays in obtaining authorization, impacting patient care and overall revenue for healthcare providers.
Anticipating the continued trend of insurance companies favoring the fax-in method, healthcare organizations should invest in training staff on the proper procedures for charting. This will ensure that the authorization process remains efficient and that claims are processed in a timely manner. Additionally, staying informed about evolving insurance industry practices is crucial for adapting charting protocols to meet changing requirements.
Ultimately, the success of insurance authorization requests will rely on the quality of the accompanying documentation. Providers need to stay proactive in enhancing their charting practices, employing technology to streamline processes, and staying attuned to industry updates to navigate the evolving landscape of insurance authorization methods. In doing so, healthcare facilities will position themselves to maintain a seamless revenue cycle, and ultimately provide optimal care to their patients.
We're dedicated to being your trusted partner in navigating the healthcare landscape. We aim to provide insights, resources, and strategies to not only meet but exceed the challenges that lie ahead. Together, we'll make sure the year ahead is filled with partnership and prosperity in the new year.