Smart revenue integrity: Using automation to manage payer requirements

Managing payer-specific charging, billing, and claims reporting requirements is no small feat. A typical organization bills numerous payers, including commercial payers and Medicare, for services provided in a variety of setting, each with its own payer-specific requirements. It’s often resource-intensive work and errors still occur, leading to delays in reimbursement and costly denials and appeals.

By strategically automating systems from charging to obtaining consents, Carle Health, a health system based in Urbana, Illinois, has streamlined processes and reduced manual work. The organization has successfully automated systems across facility and provider types, from provider-based departments (PBD) to telehealth.

“Our gold standard is to implement […] automation wherever possible,” says Alison Davis, manager of business office operations/revenue integrity at Carle Health.

Over the past year and a half, Carle Health has experienced rapid growth even as it grappled with the COVID-19 pandemic. Having a billing and charge automation system has helped keep the organization on an even keel during a tumultuous time, Davis says.

Carle Health began automating billing systems for its PBDs in 2012, according to Davis. Billing for services at PBDs is notoriously complex and a common pain point for revenue integrity professionals. Carle Health’s solution was to automate systems to clone charges entered by physicians at PBDs to generate the associated facility charge. For example, a physician who performs a knee injection in a PBD enters their charges and CPT^© codes. Based on that information, the system creates a duplicate with the appropriate facility charges, including any medications or supplies that aren’t billed by the physician and must be routed through the facility billing system.

The automation is structured to occur seamlessly and is triggered by the location of the service, she adds.

When Medicare and other payers rapidly rolled out expanded telehealth eligibility and requirements in 2020, Carle Health tapped into its existing automation structures to stay compliant with the evolving requirements, Davis says. A standardized process was created based on the scheduled visit type and the audio/video technology used. The automated system triggers collection of the appropriate consents using a standardized template within the EMR. Charting is also standardized regardless of payer. The automated billing system then generates claims according to payers’ specific requirements.

“When the charges come over into the billing system, depending on the payer, it would pull in all the appropriate pieces that payer needed,” Davis says. “So, whether they needed the -95 modifier or the -GT modifier, whether they needed the regular place of service that would have occurred was it truly in person vs. the 02 place of service for telehealth. We built that within the system so that the claim would pull what that payer wanted.”

That means the only thing physicians and other providers need to do to ensure they bill correctly is enter the encounter as a telehealth visit. All payer-specific requirements are seamlessly mapped behind the scenes.

“It required a lot of attention from our group to make sure that we kept up on those changes and updated the system accordingly, but it really made it work more seamlessly for the rest of the clinicians across the platform,” Davis says.

Like any other process, automated systems aren’t set it and forget it. They require regular monitoring to ensure they’re functioning properly and are in compliance with the most recent requirements. All revenue cycle areas review and monitor their builds periodically in addition to regular audits conducted by the compliance department, according to Davis. Other departments also step in to conduct specialized audits.

“With the telehealth expansion, our HIM team did a great audit of the provider coding because the providers had to change quickly and learn these new workflow processes,” she adds. “Even though we tried to streamline them as much as possible, there was a need to audit to make sure we didn’t have any major gaps or issues or education needs amongst our providers.”