COVID-19—and the resulting move by the Centers for Medicare and Medicaid Services (CMS) to expand reimbursement for its use—has pushed telehealth to the forefront thanks to rapidly accelerated adoption by physicians striving to overcome pandemic-driven continuity of care barriers and maintain operations. Notably, FAIR Health’s Monthly Telehealth Regional Tracker found that telehealth claims lines increase nearly 3000% nationally from September 2019 to September 2020.
This rapid adoption, and the reality that telehealth is uncharted territory for many practices, creates some significant reimbursement risks unless providers put in place processes that ensure complete, accurate capture of documentation necessary to support coding and billing activities. As I discussed in this Physicians Practice article, Overcoming telehealth reimbursement risks, doing so will ensure billing compliance and provide a much-needed boost to the bottom line.
Anytime there is change, healthcare organizations should expect and prepare for some confusion and error. This is especially true during these chaotic pandemic times. However, acknowledging that there will be increased reimbursement risks and deploying the right strategies can ultimately mean the difference between proper reimbursement and rejected claims.
Details matter
Telehealth is untested from a claims denial standpoint and is certain to face future regulatory scrutiny. As such, physician practices are wise to adopt an attitude of “over-documenting” patient visits. Foundationally, strategies should entail documenting everything that happens during an encounter – the objective, assessment and any virtual examination or evaluation of the patient. The thought process of what a provider is monitoring and ruling out regarding a patient’s condition should also be reflected.
Key documentation risk areas that can impact claim approval include:
- Date, time and place of service
- Length of conversation
- Appropriate use
- Emergency room or outpatient consultations
- Provider recommendations
- Follow-up visits
On the technology side, documentation must reflect audio and visual capabilities and include proof of patient consent to use technology (e.g. FaceTime, Skype) that does not qualify as privacy protected.
The novelty of these care models may lend to miscommunication or areas of confusion due to the virtual nature of evaluations. For example, if mitigating liability risk is dependent upon a patient following through with prescribed measures, it is imperative that physicians document any non-compliance in the EHR with as much detail as possible.
Reimbursement best practices
A comprehensive revenue integrity strategy should entail proactive monitoring of telehealth claims to quickly identify how payers are responding to documentation practices. This monitoring should be geared toward determining why claims are denied. What is due to the regulations before CMS’s policy simplification? Did lack of documentation contribute to the denial? Or, was a denial related to improper codes and modifiers?
Providers should also engage in continuous auditing of telehealth claims for proper coding and clinical documentation to minimize denials by ensuring accurate, compliant submission. These strategies require that practices stay up-to-date on evolving guidance from both government and private payers.
Increasing resource bandwidth will likely be necessary to stay ahead of problems and identify opportunities for process improvement. Reassigning staff resources from areas where services have been reduced, e.g. billing or prior authorization departments, is one strategy that can improve the outlook. Training of coding staff must be prioritized and ongoing to recognize documentation shortfalls and ensure proper use of new telehealth codes. The reality is that clinicians will lean heavily on coder expertise during this fluid reimbursement landscape to avoid confusion.
Technology can be a critical enabler of these processes in terms of monitoring updates and changes across payer reimbursement policies and ensuring that claims comply. For example, advanced auditing solutions that automatically release new ICD-10 codes and telehealth guidance can streamline the ability of a provider to operationalize changes and support ongoing monitoring.
Looking ahead
While telehealth has faced its fair share of reimbursement hurdles in past years, recent movements have laid the foundation for widespread adoption and expansion of these services. Even after the effects of COVID-19 have passed, the industry will continue advancing remote care options to address looming physician shortages—although future uptake will largely rest with how payers behave when processing claims.
Patients will come to expect the availability of remote options following their experiences during the pandemic, so forward-thinking providers are wise to start getting their revenue integrity house in order. Those who implement systems to proactively monitor and audit their telehealth claims will be best positioned to optimize reimbursement now and into the future.
