Billing and RCM for Hospitalists: A Guide to the Essentials
How hospitalists can optimize billing
Establish systems so you get reimbursed on time, every time
Billing and revenue cycle management for hospitalists is a complex accounting process, with many quirks and idiosyncrasies, which itself hinges on clear and specific documentation and reporting of care provided. In our experience, most hospitalists don’t fully understand the billing process, and therefore underestimate what is required to navigate this process successfully.
Of course, billing and RCM are not the primary focus of any hospitalist, or any medical practitioner for that matter. While providing vital care to improve patients’ lives, billing insurance and getting paid is not necessarily top of mind - nor should it be.
Both hospitalist groups as well as independent hospitalists benefit tremendously from working with a diligent and skilled billing service. Your billing service becomes part of your support team, greatly reducing your involvement in billing issues, and delivering more reliable, timely, and complete reimbursement.
Of course, for a team to succeed, everyone must do their part. The reality of medicine is that practitioners always play the central role, and that supporting players such as your medical billing service depend on physicians to complete their part of the process.
Our billing team works with a many independent hospitalists as well as hospitalist groups, and in our experience, the following issues are most common:
Adopt the Appropriate Business Mindset
You are a highly skilled practitioner, and you deserve to be paid for your services.
This might sound obvious, but many physicians, in all specialties, struggle with this aspect of medicine. It’s incredibly common for highly-skilled, good-hearted practitioners simply let billing & RCM fall through the cracks. Some of our hospitalist clients were losing hundreds of dollars per day due to billing issues before we started working with them! They knew their billing was in disarray, but their primary concern was always caring for patients, not billing and getting paid.
For such clients, the first thing we address is mindset. The practice of medicine is a business and your liveliehood. Charity work has its place, but everyday practice in a hospital setting should be appropriately billed and compensated.
We strongly emphasize to our clients that it is imperative to address billing and RCM issues with the same level of diligence you apply to your clinical practice. Equipped with this mindset, you’re ready to begin addressing your practice’s RCM challenges.
Understand How Billing Works in Hospital Medicine
Once you have embraced the business aspect of your profession, next you need to gain a very strong understanding of how billing works for hospitalists.
In some ways, hospital medicine billing is more straightforward. Rather than specific procedures, hospital medicine billing codes are based on either the time or level of medical decision making (MDM) involved in each visit.
As with all billing codes, the Centers for Medicare and Medicaid Services assigns a Work Relative Value Unit to different levels of care a hospitalist may provide, and the wRVUs attributed to each level helps to determine the amount of reimbursement the provider will receive for the visit.
Study BIlling Guidelines THoroughly
While you don’t necessarily need to understand the entire medical billing process, it is very important to thoroughly understand the guidelines for billing codes related to your practice.
Some of the best resources include:
The Society of Hospital Medicine’s Utilization Management and Clinical Documentation trainings, a set of self-paced online courses for both adult and pediatric hospitalists
Today’s Hospitalist’s coding report
If you have access to a coding specialist, be sure to consult with them as needed
The billing codes you ultimately submit must be appropriate for the care provided in each patient encounter. It is also absolutely necessary for that encounter to be fully and correctly documented in the patient’s EHR.
The Importance of Clinical Documentation
In simple terms, your clinical documentation should address the question, “What did I do for this patient today?”
At the level of administration and management, documentation of care serves several purposes:
Allows care providers to understand the patient’s condition and medical history
Demonstrates the medical necessity of care provided in each patient encounter
Justifies the charges submitted to insurance for each encounter
Your clinical documentation should address the question, “What did I do for this patient today?”
When claims are submitted, insurance companies review them to ensure that each billing code has clinical documentation to support it. If the clinical documentation is either lacking or not aligned with the billing code, they may deny the claim.
To help avoid denials, physicians should document each encounter in a timely manner, ideally at the time of the encounter itself, or at minimum the same day. Working in EHR notes can be tedious, and all practitioners should consider employing a scribe, AI-assisted documentation software, or some combination to stay up-to-date.
Be Aware of Changes in Billing Policies
For good or bad, billing guidelines are change frequently.
For example, at the beginning of 2023, guidelines for hospital medicine underwent a major change for the first time since the late 1990’s. Among the biggest changes was that billing codes for observation and inpatient care were merged, with the new codes now covering “Hospital Inpatient or Observation Care Services.”
Most changes in billing policy are not so dramatic. However, even when billing codes are stable from year to year, the guidelines around specific situations related to each code may change frequently.
Some of the best resources to keep up to date with recent changes to hospital medicine billing policies include:
The coding & clinical documentation section of the Society for Hospital Medicine’s compliance resource page
The coding and compensation archives of Today’s Hospitalist magazine
Once again, if you have access to a coding specialist, make sure to consult them as needed
Keep in mind that even seemingly small changes to these policies can have a substantial effect on your own billing practices. For example, the recent changes to billing rules for split visits will have a major effect on hospitalists going forward.
The Role of a Medical Billing Service
The purpose of you billing service is to take your billing claims, together with their documentation, and ensures each claim is paid.
In communicating with insurance payers on your behalf, your biller greatly reduces the workload on you and your primary staff. In general, billing is relatively simple, but it can be repetitive and extremely time-consuming. We advise all physicians that, as a general rule, your primary staff should be focused on direct personal interactions with patients, either face-to-face or over the phone. Billing and revenue cycle management can detract from that, which is why it’s usually much more efficient to work with an outside billing service.
Your billing service performs several key functions:
“Claim scrubbing” or review of claims prior to submission to identify and correct potential errors
Submitting reviewed claims to payers
Tracking of submitted claims through the reimbursement cycle
Following up and correcting errors on claims that have been denied
Resubmission of previously denied claims
Reporting on the status of your claims and revenue
If your billing service is doing its job, you should receive payment within a predictable time frame.
What does this mean exactly?
As much as possible, you should try to quantify the effectiveness of your billing process. Some key reports to review include:
If your billing service is doing its job effectively, these numbers will reflect it.
The Role of an Effective Billing Service
A good medical billing service should eliminate, or at least drastically reduce, any conflict between providing clinical care and billing for that care.
In our experience, many physicians, across all specialties, often perform procedures without full confidence that they’ll be paid. Hospital medicine plays a vital role in successful treatment, and hospitalists should be empowered to provide care free from any concerns about payment. A skilled and diligent biller will ensure that, when you see patients with proper insurance coverage, you never have to wonder whether you’ll get paid.
If you have questions about your current billing situation, we offer a free, no-obligations revenue analysis to help you better understand your revenue and collections. Get in touch with us to learn more