Blog Post Category: Blog Post

Hospice care, a necessary type of medical care for those with terminal illnesses, has come under intense scrutiny in recent years due to fraudulent billing claims by a small number of dishonest providers. As agencies and committees take up the task of auditing and analyzing the billing practices of the industry, many providers are asking themselves how to restructure their revenue cycIe management to maintain their compliance. To prioritize patient care, it is essential for providers to troubleshoot their claims submissions, understand their billing data, and adopt proactive approaches to knowing every part of their RCM process.

In this blog, we’ll examine why hospice billing is under increased scrutiny, how to strengthen your RCM processes to avoid future issues and reinforcing the benefits of consistent billing and data analytics.

Hospice Billing Under the Microscope

Unfortunately, the acts of a few have caused trouble for many and hospice care providers are under more scrutiny than ever before as Medicare auditors and regulators analyze billing practices for potential fraud and overspending. With criminal charges filed against hospice providers and fraudulent billing cases making national news, it is vital for providers to understand their billing processes inside and out. Even unintentional billing errors could raise a red flag for auditors, causing unnecessary audits, disruption to patient care, or loss of Medicare certification.

With an increase in audits and regulations, it is essential for hospice agencies to review their revenue cycle management processes as a critical part of the business. A well-structured and thorough approach to your RCM can help reinforce your financial stability and legal standing as a hospice agency.

Auditing Red Flags

Auditors closely examine claims to get a better understanding of how hospice agencies bill for and use resources. Inconsistencies on these claims will immediately raise concern as to whether a hospice provider’s incorrect billing resulted in overpayment for services. As oversight intensifies, auditors and regulators are closely examining how hospice agencies allocate and bill for resources. This is especially true for Medicare, the largest payer for hospice care in the U.S., where improper billing or spending can trigger an audit.

Any of the following can raise a red flag for auditors:

• Upcoding services
• Missing documentation for billed services
• Lack of medical necessity
• Billing for services ordered by a provider, but not received by the patient

To reduce the risk of an audit, hospice providers must solidify their RCM practices and billing system. Through accurate documentation and records, remaining compliant with patient care, and the submission of timely and accurate claims, providers can vastly reduce the likelihood of

violations. To mitigate these risks, hospice agencies must implement a solid RCM and billing system that ensures accurate documentation, compliance with Medicare’s hospice coverage requirements, and timely claim submissions. With the right system in place, providers can reduce the likelihood of billing errors, missed claims, and compliance violations.

Prioritizing revenue cycle management allows hospice agencies to know their business inside and out and are well-positioned to survive an audit and avoid penalties.

Remaining Compliant with Data Analytics

At ZMark Health, we firmly believe in using data to optimize business operations and work with clients to help leverage their data to increase revenue and improve patient care. With hospice care, proactive data analysis is an effective way to maintain consistent claim filing and avoid red flag discrepancies. Monitoring your billing practices and financial data on a consistent basis can help you identify irregularities or potential issues before they escalate into compliance violations.

Proactive data tracking can:

• Track billing anomalies such as non-covered services or duplicate claim submissions (e.g., billing for services not covered or submitting duplicate claims)
• Monitor claim performance such as average days in accounts receivable or claim rejection rates
• Use patient medical records to ensure they meet the criteria for hospice care during recertification periods
• Help identify billing patterns that may lead to audits, such as a high volume of certain services performed

By using data to monitor operations, hospice agencies can maintain consistent billing practices and prevent errors that may trigger audits. Performing regular, internal audits of gathered data can help provide an extra layer of security and reveal any trouble areas that may need immediate attention.

How ZMark Health Can Help

Our team of experts have over 25 years of experience working in the hospice industry and we’re here to offer guidance and hands on support to help transform your billing practices, so you remain compliant and financially viable. We offer support in the following:

• Assistance with sequential billing issues
• Experience in collecting on VBID plans
• NOE submissions, claims billing, and collections
• Full-spectrum RCM services

Conclusion

As hospice care continues to face increasing scrutiny from auditors and regulators, the importance of a well-honed revenue cycle management system holds incredible value. Ensuring accurate, compliant billing practices not only protects your company from potential penalties but also creates a strong relationship between you and key payers such as Medicare.

Connect with ZMark Health today and learn how we can help you work through current billing issues, advise you on data analytics, and reinforce your RCM process so you can focus on providing the best hospice care possible.

Efficient and accurate medical billing is crucial for any practice’s financial health and disruptions to the revenue cycle can feel overwhelming. Managing these processes from the front end to the back end can be complex and time-consuming. As patient care continues from day to day, issues within the revenue cycle stack up over time and finding weak points in the process can feel impossible. Even with devoted staff, attentive management, and satisfied patients, issues can arise, often leading to lost revenue, compliance issues, and operational disruptions. While many healthcare providers turn to outsourcing, there’s an exciting alternative: utilizing advisory services for transparent and customized support.

Advisory services give a company the ability to optimize their revenue cycle management (RCM) while maintaining control of the billing process. Advisory services provide expert guidance on improving billing accuracy, reducing claim denials, and tracking missed payments with insurances, all while allowing you to keep the billing operations in-house. This approach helps maximize revenue and provides the internal team with additional knowledge and tools needed to implement better practices, leading to long-term stability and efficiency.

At ZMark Health, we have an experienced team of advisors ready to analyze the current operations of your practice and provide guidance on how to improve the inefficiencies of your current RCM. If you’re wondering how to turn things around without turning over full control, keep reading to learn about the benefits of advising and if this approach is the right step for your practice!

Control and Transparency

One of the main advantages of keeping your billing team in-house through the support of a knowledgeable advisor is the level of control and transparency it allows. Outsourcing means turning over financial data and access to patient accounts to a third party, which may not feel comfortable for some practices. Maintaining all current operations means direct oversight of how data is handled according to the standards set by your company.

Advisory services offer guidance and insight to help providers improve their internal processes without creating additional problems or stressors.

Cost Effective

Outsourcing RCM services can be expensive and structured to benefit larger providers through flat fees or a percentage of collections. Smaller or medium-sized providers with an interest in keeping costs low, would benefit more from short-term advisory compared to a longer commitment of outsourcing services. Costs add up quickly and targeted assistance through a consulting agreement could be the exact level of service your practice needs.

By paying for expertise only when necessary, practices can significantly reduce costs compared to full outsourcing. This cost-effective approach allows for better financial management while absorbing the benefits of professional guidance.

Customized Improvements

Every company is unique, with a set of specific needs, challenges, and approaches to patient care. Outsourced services typically use a standardized approach to revenue management and may not take into consideration all the intricacies that make your practice special. On the other hand, an advisor works closely with your team to understand how your company runs and provides tailor-made solutions to improve operations.

A personalized approach addresses more than simply improving the bottom line. Through data analytics, clinical process audits and a review of overall patient satisfaction, a customized plan is used to implement necessary changes throughout the entire revenue process.

Educate, Empower, Implement

One of the key roles of a medical billing advisory service is to educate your internal team. Rather than simply taking over the billing process, advisors work to improve the existing skills of your staff, ensuring they have the knowledge and tools needed to manage denials, patient collections, and all aspects of the RCM more effectively. These tools lead to long-term benefits through empowerment and greater understanding of processes. Your team will become more proficient and confident in handling tasks and, ultimately, reduce errors and increase efficiency.

Adding an educational component to the advisory process allows staff to learn new standards together, gain insight into the importance of streamlining the revenue cycle, and fosters adaptability in the ever-changing healthcare industry.

Scalability and Flexibility

As a company grows, the billing needs will likely evolve as well. Outsourcing may help resolve leaks in the revenue stream, but a longer-term contract may not help with increased patient volume or changes to service offerings. With an advisory service, you can utilize the support during a period of growth, stagnation, or recovery, and maintain flexibility with your operations. An experienced advisor can help a company develop tailored strategies to navigate these changes without disrupting the flow of revenue.

Consider how an outside party will support today’s problems while remaining flexible for future growth.

Conclusion

A robust and well-functioning revenue cycle is crucial for the financial health of any healthcare practice. Outsourcing might seem like the ideal solution and yield results over time but comes with trade-offs such as higher costs or loss of control. By utilizing a provider advisory service, practices can optimize their processes and empower their teams, all while keeping operations in-house.

In our blog post on analytics, we discussed how ZMark Health advisors use data to support providers and organizations. Through data analysis, our advisors gain an understanding of billing workflows and clinical processes to provide transparent and customized solutions that best fit your practice. Data assessment allows for an advisor to zone in on specific challenges and areas of improvement and allows a company to maintain these changes on their own. If you want a more efficient and effective practice, consider reaching out to ZMark Health to learn how an advisor could best support your company in reaching these goals.

Today’s healthcare landscape is constantly changing and one of the best ways to pave a successful path forward is with data analytics. Through data tracking and analysis, providers can optimize patient care and increase revenue by using current, available resources. By leveraging their data through advanced analytics, medical providers can make more informed decisions, optimize their business operations, and boost financial performance.

As discussed in a previous blog post, Revenue Cycle Management (RCM) drives a business. Once a patient is scheduled, there are many steps involved to ensure a final payment is received for services provided. Extracting and analyzing revenue cycle data from such areas as patient registration or claim denials, can improve processes within the RCM by addressing such things as staff efficiency or coding errors.

Solving Problems Through Data

Analytics in healthcare is the systematic use of data and statistics to gain further insight into business operations. To implement effective changes to any practice, it is important to understand the root cause of operational or financial problems. By analyzing data, medical providers can identify trends, uncover hidden patterns, and make data-driven decisions that can significantly impact their bottom line.

Inefficient RCM can lead to a significant loss in revenue and temporary fixes or budget adjustments will not always solve problems in the long term. To identify where to fix the problems, it is necessary to do a deep dive into the operations data. For example, reviewing all claim denials from the past year can pinpoint areas of improvement to help streamline income. Denials due to mistakes in patient registration or underpayments by an insurance company can be signs of consistent, unresolved errors or issues. Once you understand the data, you can pinpoint the areas of improvement in the revenue cycle and implement changes quickly and successfully.

Enhancing Revenue Cycle Management

Data analytics can reform the financial health of a company by collecting, understanding, and interpreting the unique data points that make up the business. Data provides insight into where and how current RCM strategies are working or falling short. Effective revenue cycle management is essential for maintaining a healthy cash flow, maximizing revenue, and creating transparent billing practices for patients. Analytics can provide valuable insights into various aspects of RCM, help providers identify areas for improvement and implement strategies to enhance financial performance.

Data analytics can revolutionize current RCM practices and change how providers manage their business. Successful implementation of actionable insights can create workflow efficiency, reduce revenue leaks, and streamline billing processes.

How ZMark Can Help

At ZMark Health, we work with providers and organizations to track revenue and improve clinical processes using data analytics. For example, by understanding the workflow between a provider and insurance companies, we help create methods to monitor gaps in data and implement changes to reduce denials and follow-ups.

Additionally, ZMark helps clients understand the relationship between clinical processes, EHR usage and data, which allows an organization to make operational changes that support more accurate and transparent reporting capabilities. When asked about data analytics, ZMark Health Director of Advisory Services Jennifer Short offered this insight: “ZMark has worked with organizations of all sizes, and in multiple healthcare industries, to increase efficiencies in operational processes which leads to enhanced visibility into data analytics and more accurate and transparent reporting. Our goal is to help our clients learn, grow and become able to maintain these new processes on their own.”

If you’re interested in learning more about how data analytics and simple changes in your RCM can transform your organization, reach out to ZMark Health today to get started!

Managing your company’s revenue cycle is a time-consuming task and directly contributes to the financial health of your business. Whether you are experiencing an increase in denied claims or a high rate of staff turnover, your bottom line is feeling the strain.

Before you connect with a consulting service, it is important to prepare yourself, so the process is efficient, and you find the right partner to meet your needs.

Conduct an Internal Audit

It is important to take your time and review the most critical needs in your business. Assess each function of your company and identify where workflow, revenue, or processes lag. Ideally, you will want to consider the areas of your revenue cycle impacting your bottom line. Even one area, such as billing, denied claims management, or patient collections, can decrease cash flow if not maintained properly.

Choosing the Right Revenue Cycle Management Partner

When researching firms, asking the right questions will help you determine if a future partner will meet the specific needs of your company. The faster you can make an informed decision, the sooner your processes and cash flow will improve. Consider the following topics before meeting with a consultant:

1. How Soon Will Claims Be Reprocessed?

If you struggle with unpaid or denied insurance claims, you will need a timeline for how soon your consulting firm will begin reprocessing claims. It is important to know if any factors, such as staff training, will impact the initial turnaround for reprocessing.

2. What is Their Experience?

Ideally, the consulting firm you choose will have employees with first-hand experience in revenue cycle management. In order to best fit your needs, an optimal partner will have successfully worked through similar billing problems with other clients.

3. What Services Do They Provide?

A seasoned and knowledgeable consulting team will be familiar with all aspects of RCM, even if they will not oversee all areas of your company’s revenue cycle. A firm may exclusively offer claims management or patient collections, but not coding services. Find a company that offers exactly what you need to help your business.

4. How Will the Partnership Increase Your Revenue?

Ultimately, you are considering a consulting partner because your bottom line is suffering, and you wish to spend more time focusing on patient care. A reputable and experienced third-party management team will have case studies and a proven track records of helping other providers like you prioritize their business needs and increase revenue.

5. Will They Communicate Regularly?

It is important to know all aspects of your business, even if part of your RCM is managed by a third-party. A consultant should provide regular reports and communications in order to exhibit how their work has improved the financial health of your facility.

Outsourcing your RCM is not an easy decision, but the best company will address any concerns quickly and confidently. ZMark Health is ready to answer your questions – and more – to help your business grow and give you peace of mind.

Revenue Cycle Management (RCM) drives your business. Once you schedule a consumer, there are necessary steps involved to ensure you receive final payment for services provided. However, like most providers, you are experiencing a financial strain due to any or all the following:

• Recruiting, training, and maintaining staff to help support the work involved with an effective RCM.
• An increased volume of consumers, providers, and participants.
• Growing consumer debt collections and a decrease in payer reimbursements.

If this sounds familiar, now is a perfect time to research outsourcing all or part of your RCM process. Managing consumer care at your organization is a top priority, but without healthy finances and cash flow you will put the success of your business at risk. If you are struggling to balance consumer care with inefficiencies in your RCM, consider the following reasons for outsourcing your billing and collections:

Better Cash Flow – Meet the demands of your growing business with help from an experienced team with an established RCM process. We will help you solve your billing challenges, opening the door for increased revenue and timely payments from insurance companies.

Reduce Expenses – Operating an in-house billing department requires a serious investment on your part but comes with the added stress of employee turnover, training, and retention. Outsourcing to a third-party company with a successful record will create optimized workflow and reduce your expenses over time.

Compliance Management – Evolving industry standards means staying up to date on billing rules, compliance regulations, and insurer submission guidelines. A consulting company stays on top of compliance rules and payer guidelines to ensure a streamlined billing process.

Prioritize Client Services – With the day-to-day tasks of billing management, claim submission, and payer appeals handed over to a trusted and experienced team, it creates more time for you to focus on consumer care.

A Deeper Analysis – Managing the daily tasks of a business office and providing client care means little extra time for analyzing your current RCM process. An outside billing company has the resources and capabilities to extract data, identify problems, and provide solutions within your RCM system. Doing so allows you to implement sound billing practices and solidify the financial health of your company.

Gain an Edge with ZMark Health

We are here to provide guidance on or manage your Revenue Cycle Management process. With our services, you will increase profitability and improve efficiency. Contact us today to learn more about the support we can provide.

As a Human Services provider, it is becoming increasingly challenging to manage consumer payment responsibilities from commercial insurances. Provisions under the Affordable Care Act are increasing the amount of money consumers must pay, and as a result commercial insurances are placing more financial responsibility on their members: your clients. It is essential to develop policies to communicate these expected costs to your consumers while prioritizing the financial health of your organization.

Consumers walk through your doors and present a wide variety of commercial insurances, each with unique benefits, copayments and deductibles to consider. Because of these complexities, your team needs to be prepared to effectively manage and communicate the financial responsibilities that fall to each client. Developing and consistently implementing a consumer-driven payment policy helps create a trusted relationship with your clients – a must for behavioral health organizations in a value-based care setting.

It is important to consider all outcomes when developing a consumer-centric policy, including a denial of service if an individual cannot cover their financial responsibilities. Working in conjunction with your care teams on policy formation ensures the best interest of the individual is at the forefront. Your business depends on how effectively you manage consumer payment responsibility as well as how consistently a policy is implemented. If you’re looking for a place to start, here are a few key tips:

1. Develop Your Plan – Before you implement changes, you must develop a policy that fits the needs of your organization and the individuals you serve. Engage your clinical team in developing policies so everyone involved in consumer care contributes to, and understands, the new consumer-driven plan. When a question arises from a client, your team member can refer to your established policy to provide consistent answers and plan of action without question or hesitation.
2. Train Your Team – Once a policy is developed, train your staff, particularly your team members working the front desk, on how to have effective payment conversations with consumers. This can be a difficult conversation and can take practice for your team to become confident and clear in their communication. Arm them with talking points, resources, and leadership support so they can effectively engage with your consumers and are able to collect payments at time of service with ease.
3. Review Coverages – As mentioned, your clients will present a wide variety of commercial insurances. Behavioral health organizations need to mirror the practices implemented by many physician offices. Learn the individual’s current insurance status beyond “active” or “inactive.” Understanding their deductible, what services are covered, copays, effective dates, and if authorizations are required will prepare you for providing excellent customer service to your consumers. You will be able to answer questions, advise them on potential out-of-pocket costs, develop a payment plan, and give them peace of mind as you prepare them to receive care from your organization.
4. Communicate, Communicate, Communicate – It is vital to communicate the financial policy to your consumers. You cannot overcommunicate this. Every current or future client should understand your financial policy to avoid potential confusion or frustration. Effective ways to notify clients include email, direct mail, posting policies on your website, placing signage at the front desk, and discussing it during the check-in process. Communicate your policy and stick with it. In the long run, your clients will appreciate your consistency and know what to expect when they arrive.
5. Seek Outside Expertise – If you are not sure where to start or have questions on what will work best for your organization, ask for help! As a business, you can’t afford to continue with a financial policy that results in frustration from consumers and does not yield an increase in cash flow. An experienced, outside perspective can find gaps in current protocols and uncover where additional support is needed, allowing you to provide better client care and gain financial stability.

Zmark Health offers a variety of revenue management services and will give you the tools to manage the changing landscape of commercial healthcare insurances. Adapting to these shifting reimbursement models and updating your policies will allow you to keep pace with changes in the behavioral healthcare industry. Your expertise will give you a reputation as a knowledgeable, supportive organization providing top-rated customer service.