Physiatry Billing and RCM: The Essential Guide
Develop a reliable billing process
Physiatry billing has a lot in common with RCM in other specialties, but it also has a few key differences which must be managed.
Billing and revenue cycle management in a physiatry practice isn’t fundamentally different from most other specialties. However, it does have some peculiarities, which must be taken into account and managed by both physicians and billers.
As we’ve noted elsewhere, RCM is basically a very complex accounting process, one which most physicians, across all areas specialties, underestimate. This leads to well over $10 billion in challenged claims and delayed payments each year. Even worse, more than 50% of these initial denials are never resubmitted, which means that physicians never get paid for them.
Like any practitioner, physiatrists are often extremely busy, and RCM may not seem like a high priority. But losing a few hundred dollars each day adds up quickly, and inflicts serious harm on every aspect of your practice, and even your livelihood. Investing the time to find and retain a skilled medical billing and RCM partner pays off more quickly than you might realize.
In terms of billing and RCM, every specialty has its own unique features. We manage billing for many physiatrists, and we’ve noticed some of the following as recurring issues:
Approach Your Practice as a Businessperson
It’s almost cliche how many physicians have difficulty with the business side of medicine. It’s difficult for many independent practitioners to reconcile their responsibilities as a caregiver with their role as a business owner. Unfortunately, one of the most common results is that they neglect the billing & RCM aspect of their practice, and lose revenue to delays and denials. We work with several physiatrists who were losing hundreds of dollars per day before they became our clients. In other specialties and larger groups, it’s not uncommon for practitioner to lose thousands of dollars of revenue every day due to avoidable issues with billing!
Our first piece of advice is, if you think you have RCM issues, take action. The sooner you address these problems, the sooner you can get back to your primary concern, which of course is caring for patients. Left unattended, problems with RCM will become a drain on both your energy and your finances.
So don’t put this off. It may be a bit more work up front, but you absolutely will not regret investing the time to solve your RCM issues.
Understand the Steps of RCM in Specialty Practice
Patient encounters in physiatry follow a predictable and set sequence, with each step dependent on the ones before it. Each step has a significance both for clinical purposes and in the billing & RCM process. Just as you’re diligent and thorough in caring for each patient, you must similarly attend to the RCM elements of each encounter with consistency and precision.
STEP 1: Receive REFERRAL FROM the Patient’s PCP
For patients who have HMO coverage - which is the vast majority - a referral is the required first step before visiting a specialist. The primary care provider makes the initial evaluation, concludes that he or she requires specialized attention, and refers the patient to you. With respect to the RCM process, referral from the PCP is a prerequisite to everything that follows, and it must be documented and tracked.
The referral itself hinges on the concept of “medical necessity” as determined by the PCP. Like the referral, medical necessity will also come into play throughout the billing process, and must be tracked and supported by documentation throughout.
STEP 2: INITIAL APPOINTMENT and EVALUATION
This is when you first see the patient, and determine what type of care is required. While the initial appointment is usually billed as a simple office visit, subsequent care will be billed according to specialty procedure rates, which are often much, much higher. Perhaps you’ll recommend an EMG, an NCS, joint or trigger point injections, ultrasound, plasma injections or something else. Perhaps simple physical manipulation will be sufficient. Regardless of the course of treatment, appropriate documentation of medical necessity in your EHR is absolutely vital.
Your biller must now fulfill several new tasks:
Deliver your EHR notes to the patient’s insurance provider
Ensure your recommendations are within the parameters of “medical necessity” as determined by the patient’s insurance
Obtain an authorization or approval from the patient’s insurance to cover your recommended course of treatment
From your perspective as a physician, all of this occurs in the background, as you proceed with treating and caring for your patient.
In our experience, most physicians will proceed with treatment on the assumption that their biller has everything in order, and that they will be paid. From a clinical perspective, treating the patient ASAP is clearly preferable, but from a business perspective, there is a risk of not getting paid if your biller makes any mistakes.
STEP 3: DETERMINING MEDICAL NECESSITY
In theory, it would seem like the “medical necessity” of care should be exclusively, or at least primarily, determined by the physician. In reality, however, the patient’s insurance company has an independent process for evaluating the medical necessity of each course of treatment.
From the insurance company’s perspective, a claim of medical necessity usually rests on a number of different criteria, such as:
The patient having insurance for at least a minimum period of time
The patient experiencing their health issue for a minimum period of time
The patient’s health issue being the result of an underlying condition
The physician having attempted other interventions, which have not resolved the patient’s issue thus far
The above are some examples, and there may be others, depending on the specific course of treatment for each specific patient.
In terms of demonstrating and documenting “medical necessity,” the key takeaway is that your clinical notes must specifically fulfill all of the insurance company’s criteria for approving that specific course of treatment. On the insurance company’s side, an auditor, rather than a physician, is most likely responsible for making these evaluations of medical necessity, although physicians will certainly be involved in setting the parameters for such evaluations.
STEP 4: DEMONSTRATING AND DOCUMENTING MEDICAL NECESSITY IN YOUR CLINICAL NOTES
If the patient’s insurance company reviews your notes, and for some reason determines that your recommended course of treatment doesn’t meet their criteria for “medical necessity,” your claim will be rejected. In many cases, you may have already done the procedure before you learn the claim has been rejected.
In our experience, many rejected claims are related to issues with the clinical notes from the initial evaluation. Different insurance companies have different requirements related to information that must be included in the note in order to demonstrate medical necessity. By itself, this might seem confusing, but what’s more, these requirements may change at any time. In practical terms, it’s nearly impossible for even the best billers to keep up with changing requirements of individual insurance companies.
Nevertheless, a good billing process can ensure you get paid despite these complex and often convoluted requirements. Your should work with your biller to ensure the following:
Use robust global templates in your EHR notes, to ensure you include all required information and meet necessary criteria
If a claim is rejected, your biller should immediately contact the insurance company to determine the specific reason for the rejection
Your biller should ensure you make edits and updates to your clinical notes ASAP, so the claim can be rebilled
Once you understand the insurance company’s new requirements, should update the global template in your EHR to include any necessary information
In practice, you can update your notes and rebill each claim as many times as necessary. However, each rejection causes a delay in payment, and requires more work from you and your team, so you should strive for efficiency.
STEP 5: PERFORMING THE PROCEDURE AND COURSE OF TREATMENT
From a clinical perspective, it’s extremely important that billing issues don’t hinder you from providing care. From the time you first evaluate a new patient, you should be free to follow the best course of treatment you possibly can.
For example, when you evaluate a patient who is in severe pain, and determine that an epidural steroid injection is medically necessary, you should be fully empowered to perform that procedure at the earliest possible time. However, it must be noted that this involves a significant up-front expense on your part, for both the medication and operation of equipment.
Your biller must ensure that the demands and urgency of providing care do not conflict with the necessity of getting paid for this care. You should never find yourself wondering whether you’ll be paid for a procedure or course of treatment. If the patient is covered, you should be able to proceed with full confidence that the billing process will be managed successfully. If for some reason the patient is not covered, you must be made aware of this in advance, so you can choose the best course of action.
STEP 6: WAITING FOR CLAIMS TO BE PAID
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.
Many physiatrists are extremely busy, often seeing many dozens of patients per day. If every aspect of your practice is running smoothly, this extremely high workload can be sustainable and successful, but if there are any issues or inefficiencies, mistakes can be compounded rapidly. This is especially true for independent practitioners, who have minimal or no office staff supporting them.
A skilled billing partner, that is familiar with the details of physiatry practice, is a key asset. A relationship with such a biller will pay off many times over, both in terms of revenue, and in terms of peace of mind and efficiency of day-to-day routines.
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 see if we can help.