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Physical Therapy EMR and Billing Software: Ensuring Accurate, Current Claim Information

Physical Therapy EMR and Billing Software

Physical therapy billing without challenges? That may sound too good to be true. Experiencing denials or smaller payments than expected is not an experience that PTs look forward to. But it is unfortunately part of the day-to-day billing process at most clinics. Solving these challenges requires the right processes along with the right Physical Therapy EMR and Billing Software.

Processes for Challenges

Essentially, physical therapy billing would boil down to providing services, submitting CPT codes, and receiving payments for the services.

Challenges could be many.

  • Rejections, denials, and reimbursement delays would come with the territory. It may not always be easy to determine exactly where something went wrong.
  • A case in point could be that of multiple therapists delivering several specialties to the same patient on the same day. This could in turn increase the prospect of denials.
  • Any services performed on a date of service would all likely get grouped together at the payer end, even if they were to be put on separate claims.
  • If a patient were to get PT, OT, and Speech on the same day, the appropriate modifiers would have to be used. Despite that, it could still lead to a denial that would need to be appealed.

The most likely cause of claim denials would be incorrect information on the claim. The way to improve the first pass resolution rate would be to make sure that every item of information added to a claim is both accurate and current.

On the path to accurate, current claims would be implementation of the right process within the clinic for verifying patient insurance eligibility and demographic information, before the first visit and at specific time intervals going forward.

  • That way, it would be possible to know if the patient is eligible to receive coverage for services as well as what information the insurance company would need to pay the claim.
  • An example of prior information would be if the insurance company requires pre-authorization or a physician referral.

Claim information would also need to include the number of visits covered, visit timeframe, number of visits already utilized by the patient, and if PT services are combined with other services like OT and Speech. Even a seemingly simple matter of verifying the payers mailing address could prove to be critical.

Some other steps that would solidify claim information and more:

  • Application of accurate codes, minutes and modifiers when creating a claim.
  • Defensible documentation that supports the use of codes, minutes, and modifers.
  • Determining the patients financial responsibility for services.
  • Communicating financial responsibility to the patient prior to the first visit.
  • Establishing a policy for collecting payment at the time of service.

Software for Processes

Ensuring accurate and current claim information would likely require an integrated Physical Therapy EMR and Billing Software that would put all the pieces of the billing puzzle together.

Documentation is where it would begin.

  • Providers would mark their charges in the EMR flowsheet.
  • Billers would typically create claims after the encounter is marked as signed off.
  • Default modifiers would be added based on the patients payer class.
  • Billing rules set up during implementation would automatically assign modifers.

Next up would be claim scrubbing in the billing software:

  • What would come in handy would be a report workflow tool with links and buttons to traverse the workflow to fix charges at any time.
  • Running a charge review report would list all charges created. It should be possible to navigate to the underlying case, payer, backend charges, underlying note, and so on.
  • Billers would be able to correct information in the charges summary. They could also send the encounter back to the therapist to fix charges by assigning a task to the therapist.
  • Billing teams and therapists would work seamlessly during the charge review process. Claims being corrected could be excluded from final processing.
  • Typical units per visit of say three to five units per visit could be set as a guide to flag claims that are going over and under.

That would be followed by creating a batch of claims in the billing system for transmission to the clearing house.

  • Narrowing down the type of claims that go into the batch would come next in the find claims process. This would run another rules engine to catch additional inconsistencies.
  • These would be un-transmitted batches that have not yet been sent to the clearinghouse. The next step would be to validate claims.
  • Splitting the batch would let the green, all clear claims go through. This would make it possible to dive deeper into the red claims batch.
  • Making changes could be accomplished by updating the claim form or by fixing the underlying patient record itself.
  • Deleting the claim would mean that the claim would likely shift to the next batch. Once the batch of claims would be all green, it would be ready for transmission.

Sending claims to payers could be done electronically or by printing paper claims. Creating tasks to follow up on payments in the future would help cash flow. Follow up timelines at the payer class level could be set up during implementation.

Then, it would be over to ERA posting in the billing software:

  • Typically, most payers should be set to electronic ERA remittance posting where outstanding ERAs would be downloaded directly from the clearing house.
  • ERAs could be filtered by billing entity. In the posting screen, billed amounts, contract amounts, and paid amounts, as well as adjustment codes and reasons could be reviewed.
  • Billers could choose to override adjustments and not write them off, leaving the amount in the primary balance or in patient balance.
  • Billers could also auto post ERAs or override individual line items on a case by case basis. Some ERAs could be unmatched in the case of a transition to a new EMR.
  • Unmatched ERAs represent payments that dont match charges in the current system. These would likely need to be handled in the old EMR, if possible.

Patient statement processing would complete the cycle.

  • The first step would be to allocate patient money collected, the available money in the system. Next would be to create patient statements for unpaid patient responsibility.
  • Statements could be sent to the patient portal for patients who are registered with the portal. Printing paper statements for the rest or for all would close the loop.
  • Print statements could alternatively be sent to a print service that would take care of patient statement fulfillment, directly from the billing software.

Physical therapy billing challenges are unlikely to just fade away. But combining the right processes with the right Physical Therapy EMR and Billing Software would enable accurate and current claim information and reduce the frequency and magnitude of billing problems.