Optimizing Business Processes for Telehealth Services
Originally published on June 15, 2021
Updated on October 31st, 2023
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At the onset of the COVID-19 pandemic, lockdowns forced healthcare providers to quickly deploy telehealth services to safely see patients. Using the internet, video conferencing, streaming video, imaging, telephone calls and other electronic communications, they could remotely diagnose, treat and monitor patients who couldn’t receive in-person medical care. While telehealth had already existed for years beforehand to serve patients remotely for a variety of reasons, the pandemic brought the use of this technology front and center.
Now, however, the country is rounding a corner on COVID-19. Many providers are considering whether these rapidly implemented telehealth business processes and policies are effective for optimizing reimbursement opportunities and reducing compliance and privacy risks. They’ve often experienced lost charges, lower than expected reimbursements, and denials for untimely filing, coding errors, incompatible services and lack of coverage. And as with any technology-based operations, cybersecurity and privacy become concerns.
All of these issues affect the financial well-being of their practices. Some providers may also be subject to retroactive audits of their coding and medical record documentation for telehealth services. So if you’re continuing telehealth services (or considering starting them), here are a few areas to keep in mind.
Establishing Sound Business Practices for Telehealth
Patients generally enjoy the safety and flexibility that telehealth provides for both routine and chronic care. But with the sudden onset of the pandemic, some providers didn’t have the time and resources to develop the policies, procedures and controls to sustain telehealth for the long run. Even those who took additional time to implement telehealth have struggled to improve their related business operations and functions.
Telehealth is likely to remain a significant channel of healthcare delivery well beyond the pandemic. Providers should analyze the effectiveness of their current policies, procedures, systems and controls to refine their operations, maximize financial opportunities and reduce risks.
A comprehensive set of policies, procedures and controls is foundational to establishing a long-term telehealth program. They should be separate from those used for traditional service delivery and designed specifically for telehealth services.
Focusing on the Accuracy of Coding and Billing
Many providers have experienced denials for telehealth services after the fact. Procedures should be implemented and monitored to ensure the accurate use of billing codes and the timely processing of billable services, remittances and claims follow-up. A provider’s telehealth policy should require that coverage verification be completed with the patient’s payer before the first telehealth visit. This will result in fewer denials and higher reimbursements.
It’s important for business office staff to know each payer’s specific requirements for coding and billing. Medicare and commercial payers often require the use of different current procedural terminology (CPT) codes for the same telehealth services provided, making coding and billing complex. For example, Medicare maintains a large list of eligible CPT codes, while some private payers prefer the use of a single telehealth code. The accurate use of service codes and billing modifiers ensures that a claim will be paid. The documentation of medical necessity is critical for telehealth claims, as is documentation under the principles of evaluation and management (E/M) coding.
Healthcare providers should perform quality control audits for coding to ensure compliance and address lost revenue issues. For example, telehealth bills may have been “under-coded” due to misunderstanding the guidelines or the different payer requirements. These audits highlight problem areas and provide opportunities to initiate process improvements.
Many commercial payers have different requirements for submitting bills for telehealth services than for traditional office visits. To further complicate things, they often change their telehealth billing requirements on short notice. So it’s important for staff to visit payers’ websites frequently. Closely monitoring their evolving requirements helps your practice remain up to date with payer correspondence.
Improving Charge Capture
Healthcare providers can use various tools to analyze unbilled telehealth visits. These tools reconcile the number of scheduled sessions with the number of sessions actually billed, complete with explanations for canceled, no-show or unbilled sessions. This helps staff ensure unbilled charges are captured and resolved in a timely manner to avoid denials due to late billing.
Charge capture tools can estimate the amount of reimbursement expected from each payer for each telehealth session. Because many payers have telehealth rates in effect for a limited amount of time during the pandemic, these expected payment amounts should be monitored and adjusted frequently to provide accurate cash flow projections. Staff should investigate discrepancies in the amounts received against estimated reimbursements. Providers also can use benchmarks to develop expectations for telehealth reimbursements and better understand the reasons why average reimbursement may differ from the relevant benchmarks.
Because payers view telehealth services differently than in-person services, healthcare providers should establish a separate telehealth denials management program. The goal of the program should be to recover bills that have already been denied and identify their root causes to prevent similar denials in the future. A sound telehealth denials management program should include:
- Compilation of telehealth denials
- Denials tracking and trends
- Recommendations for remediation of specific denial reasons through process improvements or education
- Tracking claim recovery results by denial rate and turnover rate
- Reporting functions for claims recovery results
- Ongoing processes to capture prospective prevention results
Maintaining Patient Privacy and Reducing Risks
In the rush to provide telehealth services online, many providers had to hastily set up their technology. Stay-at-home orders in several states forced some providers to work from home on personal computers with limited security protocols in place. Even those providers who could be at the office sometimes needed to work with patients choosing to stay home.
These circumstances put providers at increased risk for cybersecurity breaches and violations of patients’ privacy under the Health Insurance Portability and Accountability Act (HIPAA). It also left them and their patients vulnerable to cybersecurity breaches and theft of protected health information (PHI).
Healthcare providers should actively engage their organization’s IT professionals to ensure appropriate cybersecurity protocols and procedures are in place. This in turn reduces the risk of security breaches and violations when conducting telehealth appointments. Security software, secure remote access to internal healthcare systems and the use of virtual private networks can help providers maintain secure connections and protect their patients and their practices.
With telehealth affecting so many aspects of your practice or facility, it’s important to seek advice if you have questions. Your healthcare CPAs and seasoned technology professionals can help you achieve successful and secure telehealth procedures.
All content provided in this article is for informational purposes only. Matters discussed in this article are subject to change. For up-to-date information on this subject please contact a James Moore professional. James Moore will not be held responsible for any claim, loss, damage or inconvenience caused as a result of any information within these pages or any information accessed through this site.
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