Two Payor Practices Complicating the ED Revenue Cycle — and What Providers Can Do About It

June 3, 2020

Both commercial and federal health plans engage in various payor practices that complicate the emergency department revenue cycle, says Ed Gaines, JD, CCP, chief compliance officer at Zotec Partners.

Mr. Gaines discussed the various payer-related challenges associated with ED coding and billing processes and shared a few strategies to ensure successful reimbursement during the Becker’s Hospital Review 9th Annual Meeting on April 12 in Chicago.

One major challenge Mr. Gaines discussed is CMS’ Targeted Probe and Educate program, which aims to help providers reduce claims denials through one-on-one help with a Medicare Administrative Contractor. CMS selects providers with high claim error rates or unusual billing practices that aren’t compliant with Medicare policy to participate in the TPE program.

“What’s concerning about the TPE process is at end, if they deem you have not been fully educated or otherwise modifying your behavior, they can refer the matter to the uniform program integrity contractor or do a statistical sampling, allowing them to extrapolate an error rate across your universal claims,” says Mr. Gaines. “That’s when the dollars get really significant.”

To avoid this outcome, Mr. Gaines recommends healthcare providers educate auditors on ED coding, pay attention to the TPE timelines, absorb the education from CMS and change their policies if applicable.

Another major issue plaguing emergency departments nationwide is Anthem’s discretionary policy in which medical conditions deemed nonemergent are excluded from coverage. “It’s causing huge consternation within the patient and clinician community,” says Mr. Gaines.

To limit the amount of claims identified as nonemergent, hospitals and other healthcare providers should instruct coders to strategically sequence patient diagnoses and avoid using unspecified codes when possible. Providers can also join state and federal efforts against these types of policies and turn to litigation — or the threat of litigation — if necessary, according to Mr. Gaines.

Learn more about Zotec Partners here.