InSights

An EHR’s Undeniable Role in Billing

Of course, an AI-driven EHR is relied on for clinical charting and reporting, and for an array of ancillary functions from e-Rx to its roles in telemedicine, remote patient monitoring, clinical decision support (when needed), and for interoperability as called for in the 21^st Century Cures Act.

Today, the AI ability of an EHR to automatically - and ambiently - capture relevant clinical conversations between patients and providers and insert that content correctly into patients' records, with providers remaining hands-free, is revolutionizing how encounters are being completed.

All of this and more creates an EHR that works for the provider, not vice versa. Let’s not forget that, ultimately, it all works to benefit patients even if they don’t realize it.

Ancillary is too weak a word, but an ancillary benefit of an AI-driven EHR is how it instantaneously prepares (or should prepare) the claim with everything in order as needed, including with complicated E/M and hierarchical condition (HCC) coding applied for maximized reimbursement, and then with NCCI editing to ensure that multiple claims for a single patient are bundled correctly into a single master claim, again when needed, to avoid denials on those individual claims.

In other words, the EHR must/should be “thinking” about a myriad of actions needed to ensure the clinical and financial integrity of each encounter.

To complete the EHR circle, if it’s ONC certified, then it complies with the 21^st Century Cures Act and ensures you’re not in jeopardy when it comes to being interoperable and that you don’t engage in information blocking.

In short, you’ll want to ensure your EHR is doing its part to keep you fluid, mobile, efficient, compliant, and financially sound!

(ADSRCM clients can access the ONC-certified MedicsCloud EHR, which operates as described and is ideal for dozens of specialties, or if preferred, they can keep their existing EHRs interfaced with us.)

The No Surprises Act, Revisited

In effect since New Year’s Day, 2022, we thought this would be a good time to revisit the No Surprises Act (NSA), starting with a simple definition: the NSA was created and designed to protect patients against unexpected medical bills to the extent possible. As you’ll see, it’s more challenging to do that in emergency situations, but then the NSA calls for capping out-of-network costs for those same emergencies.

You can no doubt see how out-of-network (OON) situations would be more prevalent in emergency settings where the patient really has no control over the services being provided (for example, the ambulance, anesthesia, radiology) and perhaps even providers who are performing the actual procedures such as surgeons and ER physicians. Keep in mind that even if the facility itself is in-network, the individual providers treating the patient may not be.

In these OON situations, claims are typically submitted to the patient’s insurance. The payer determines how much it would pay and then reimburses, which results in the patient receiving a balance-due statement, otherwise known as “balance billing.” This makes up a surprise bill since the patient is often unaware until the statement arrives.

There might also be cost sharing if there are copayments or co-insurance. These are often not approved in advance and are typically surprise bills in emergencies.

Here are some guidelines:

• The NSA reduces out-of-network fees for emergency services by deriving an amount close to what an in-network provider would be paid, often by using what the patient’s insurance would’ve paid if in-network.      
• What about in-network facilities that have out-of-network providers? If the patient has services provided by out-of-network practitioners without prior approval, the amount charged for this care is limited by the NSA. Again, the patient’s in-network insurance rate is often used as a guideline.
• Lower out-of-network cost-sharing fees: Since out-of-network cost-sharing for the patient is generally more expensive, the NSA typically eliminates surprise billing arising from out-of-network cost-sharing for most emergencies and even for some non-emergency care.
• The NSA and EOBs: To not be duped into approving balance billing without fully understanding options and scenarios, patients must be notified of their full billing protections before being asked to sign any waiver of said protections. Patients can waive their protections, but only after being notified as described.
• Ensures good faith estimates. How would patients be able to ascertain how much they’d be billed for medical care? What about uninsured patients or those opting to not pay through their insurance? The NSA calls for patients to receive good faith, close approximate estimates for their cost of care in advance of service(s) being rendered.

As mentioned at the beginning, this is a basic revisiting of the NSA. Many other facets of it can be seen by clicking here for CMS and the NSA, including what patients can do to report violations of the NSA.

Indeed, the overriding concept is to avoid surprise billing and adhere to the reimbursements approved as described above.

(Our MedicsPremier platform enables ADSRCM clients to get out-of-network alerts in advance. Clients can then select in-network providers, if any, for the patient and the expected procedures. The MedicsPremier Patient Responsibility Estimator, while scheduling appointments or any time in advance, provides close approximations of what will be owed to help avoid those surprises. The estimator can be used again as patients leave and the actual procedures are performed. These tools work to avoid surprises and help keep patient A/R more tightly controlled.)

Next Up:

March with more items of interest!

Contact us at 844-599-6881 or email rcminfo@adsc.com for more about how you can drive maximized revenue and productivity with ADSRCM, which includes access to the ONC-certified MedicsCloud EHR and its built-in MedicsScribeAI for natural language data capture during encounters. Clients can also retain their existing EHRs if preferred. The platform we use (the MedicsCloud Suite) is available from ADS if in-house automation is preferred.

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