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The COVID-19 pandemic has placed a great amount of strain on the healthcare industry and as a result, providers have had to adapt in order to provide care to their patients and continue to maximize their revenue. One way many providers have evolved throughout this trying time is by implementing the use of Telemedicine throughout their practices. Telemedicine is an effective means to provide remote patient care by using the latest telecommunication technologies. This includes the use of interactive audio and video telecommunications between the patient and the healthcare provider.

There are multiple options when incorporating Telemedicine into your practice, and each may target a different set of specific needs. One way to implement Telemedicine practices is via your patient portal. A Telemedicine option may be built into your patient portal and integrated into your EHR workflow. This option is beneficial because most patients are already familiar with the patient portal and therefore the experience is efficient and hassle-free.

Another option for implementing Telemedicine practices is utilizing an EHR-integrated application. This involves the use of a third-party application which allows the access of patient information, Telemedicine sessions, and more. This is beneficial due to the ability to access scheduling and patient information which allows higher efficiency for providers.

The third option for implementing Telemedicine practices is a standalone solution. With this option, your EHR would be used for scheduling, documentation, and billing; the Telemedicine solution would only facilitate communication with patients. The benefit to this option is lower costs, less or no contractual commitment, and a faster implementation.

In order to choose the right Telemedicine solution for you and your practice, there are key factors that must be considered. If you are looking to begin Telemedicine immediately, you will need to account for the time necessary for implementation. Many Telemedicine solution vendors have long implementation timelines due to high demand during this pandemic.

Another factor to consider ease of use of technology for the patient and provider. Depending on your patient demographics, there may be barriers to use for specific vendors that require more support. Provider experience is equally important, as choppy workflows caused by ill-fitting Telemedicine solutions could affect the productivity and revenue of your practice.

Another consideration for your practice is if the investment is worth the cost. When beginning to look for Telemedicine solutions, it’s beneficial to find a reasonably priced option with short term commitment that allows you to explore what capabilities are most important to you. Lastly, it is extremely important to find a solution that is HIPAA compliant and allows for providers to obtain consent for a Telemedicine visit in accordance with state requirements to protect PHI.

Telemedicine has been proven to be an extremely useful tool for practices across the nation as we continue to navigate through the challenges caused by COVID-19. If you are interested in finding out what Telemedicine solutions that may work best for your practice, click here to learn how TriumpHealth can assist you in evaluating your options and maximizing your revenue.

Throughout the entire credentialing process, there are multiple situations that may occur and can affect the timeline of a provider’s credentialing. Some of these situations can be avoided or prepared for ahead of time which will result in a much smoother process without delays.

The average timeline for provider credentialing has been 120-150 days during the COVID-19 pandemic time. This can be extended even further when the documentation needed for credentialing is submitted late or is incomplete. Delays caused by incomplete documentation or negligence can be easily avoided if you follow the tips below:

  1. Respond to requests from your credentialing consultants in a timely fashion. Please understand this process involves teamwork, and ifthe delivery of documentation requested is delayed, this will affect your credentialing timeline.
  2. Make sure that all legal incorporation documents, bank account information, bank letters etc. have the same legal business name and address on them. Be aware that spaces and punctuation do matter, if there are any inconsistencies the application will be flagged and denied, resulting in further delays.
  3. Make sure each provider’s CAQH is up to date, accurate and attested.
  4. Be prepared for unique scenarios to arise throughout the process. We try and work with you proactively to request all of the information the payers may need up front however, there are scenarios where additional information may be requested by the payer to complete your enrollment.
  5. Plan ahead and know when you expect to start billing out claims and receive reimbursements. Also bear in mind that in order to bill in network claims successfully, some payers can take up to 45 days to upload the new contract into their internal systems after the contract is received.

Utilizing these tips will help cut down any delays caused by human error and will allow your credentialing consultants to complete your credentialing in a timely manner.

We understand that provider credentialing takes patience and persistence, and that is exactly what TriumpHealth’s credentialing consultants deliver to each and every provider that needs our assistance. If you have any questions or want to learn more about TriumpHealth’s provider credentialing and medical billing services, please feel free to contact us at 888-747-3836 x 1 or email Madison at madison@triumphealth.com.

Payer contract negotiation is a complex and often stressful process, but it is extremely necessary to ensure maximization of revenue for providers. Most healthcare practices leave the task of contract negotiation to their practice manager or administrator. However even managers with a number of years of experience running the practice may not realize that their practice has more bargaining power than assumed.

Knowing when contracts renew and when payers require notification from providers for negotiation is a significant first step to successfully negotiating payer contracts. It is critical to review contracts and make note of important dates so that they are not missed. Although it sounds simple, when a provider or facility has a large number of contracts in place, renewal dates can be easily overlooked. One important part of keeping up with these dates is knowing where payer contracts are saved so that they are easily accessible for review. Without having the contract readily available, one won’t know when to take action for negotiation.

Secondly, it is important to perform a payer reimbursement analysis on the key services offered or the higher frequency CPT codes used by your practice. One should calculate the revenue generated from the specific CPT codes and compare that to the practice cost inclusive of physician reimbursement and overhead costs. Identifyingpayers who paylower than contracted amounts for specific CPT codes is also a good way to find out where revenue is being lost. This will give you a better understanding of the payer contracts that need to be reviewed and potentially negotiated with the range of reimbursement expected to generate profit.

Thirdly, it is imperative to closely review the contract language and terms, especially the evergreen clauses. These clauses make the contract renew automatically unless a termination notice is given in advance of the term end. You should always try to negotiate a clause that allows termination of contract with a 90-day notice period to avoid being in a losing situation.

Another situation that can cause loss of revenue is retroactive denials resulting in demands for refunds on claims, including those that are several years old. It’s important to make sure that there is wording in the contract that prohibits automatically withdrawing payments older than 120 days unless there is a problem within the claim itself.

Other factors to consider for better contract negotiations include:

  • Are the payer’s timely-filing rules reasonable?
  • What is their definition of medical necessity and covered services?
  • How do they reimburse most frequently-used modifiers?
  • What fee schedules and payment guidelines do they use?
  • Relative Value Units (RVUs)
  • Patient Volumes
  • Claim Filing Limits
  • Appeals Qualifications
  • Market Value Based on Taxonomy

Before the contract negotiation process can begin, each provider or facility needs to clearly know what is included in each of their contracts that they wish to negotiate. This requires a complete and comprehensive contract review as well as a high-level understanding of contract terminology.

TriumpHealth’s team of payer contracting specialists can review your contracts and identify all improvement opportunities with you. Our consultants find where you would benefit from negotiation and ensure that your contract contains optimal terms in the process. Let TriumpHealth handle your payer contract negotiations and help you maximize your revenue today.

Since 2020 has ended and the new year has begun, it is important to stay abreast of the new requirements for MIPS in 2021. Below is a list of key highlights that will play a large role in how you report for MIPS this year.

MIPS Category Changes

Performance Category 2020 Weight 2021 Weight
Quality 45% 40%
Cost 15% 20%
Promoting Interoperability 25% 25% (no change)
Improvement Activities 15% 15% (no change)

Quality Category

For 2021, you must still report 6 measures for at least 70% of your eligible Medicare Part B patients for the year. The following changes have been made to this category:

  • 12 Measures have been removed from the MIPS reporting
Quality Measures Removed for 2021
#012 Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation (*this measure will still be available for reporting as an eCQM)
#069 Hematology: Multiple Myeloma: Treatment with Bisphosphonates
#146 Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Screening Mammograms
#333 Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)
#348 Implantable Cardioverter-Defibrillator (ICD) Complications Rate
#390 Hepatitis C: Discussion and Shared Decision-Making Surrounding Treatment Options
#408 Opioid Therapy Follow-up Evaluation
#412 Documentation of Signed Opioid Treatment Agreement
#414 Evaluation or Interview for Risk of Opioid Misuse
#435 Quality of Life Assessment for Patients with Primary Headache Disorders
#437 Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure
#458 All-Cause Hospital Readmission (Administrative Claims measure)
  • CMS has added 2 administrative claims measures
    • Hospital-Wide, 30-day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups
    • Risk-standardized complication rate (RSCR) following elective primary total him arthroplasty (THA) and/or total knee arthroplasty (TKA) for MIPS Eligible Clinicians

Promoting Interoperability (PI) Category

CMS has made the following changes to this category:

  • Retained the Query of PDMP measure as an optional measure and makes it worth 10 bonus points.
  • Changed the name of the Support Electronic Referral Loops by Receiving and Incorporating Health Information measure by replacing “incorporating” with “reconciling”.
  • Added an optional Health Information Exchange (HIE) bidirectional exchange measure.
  • Preserved the automatic reweighting policies for the following clinician types:
    • Nurse Practitioners (NPs)
    • Physician Assistants (PAs)
    • Certified Registered Nurse Anesthesiologists (CRNAs)
    • Clinical Nurse Specialists (CNSs)
    • Physical Therapists
    • Occupational Therapists
    • Qualified Speech-language Pathologist
    • Qualified Audiologists
    • Clinical Psychologists Registered Dieticians or Nutrition Professionals

Cost Category

Aside from the weight change to 20% for the overall MIPS score, there have not been any major changes to the Cost Category. CMS has maintained the existing Cost measures from 2020, and they have added telehealth services directly applicable to existing episode-based cost measures and the TPCC measure.

Improvement Activities (IA) Category

There have been no major changes to this category for MIPS 2021. CMS has continued the COVID-19 clinical data reporting Improvement Activity with a modification to the activity description (see below for requirements).

  • MIPS eligible clinician or group must participate in a COVID-19 clinical trial utilizing a drug or biological product to treat a patient with a COVID-19 infection and report their findings through a clinical data repository or clinical data registry for the duration of their study; or
  • MIPS eligible clinician or group must participate in the care of patients diagnosed with COVID-19 and simultaneously submit relevant clinical data to a clinical data registry for ongoing or future COVID-19 research

CMS has removed “CMS Partner in Patients Hospital Engagement Network” and modified 2 activities for 2021 below:

  • Engagement of patient through implementation of improvements in patient portal
  • Comprehensive Eye Exams

Minimum Threshold to Avoid Penalties

CMS has increased the minimum threshold to avoid penalties from 45 in 2020 to 60 in 2021. In other words, you must achieve at least 60 points in your MIPS score to avoid any penalty. The performance threshold for the exceptional performance status remains the same at 85 points.

Payment Adjustments

There is no change to the MIPS payment adjustment from 2020 to 2021. This value remains at +/-9% depending on your MIPS score for 2021. The penalties or incentives from MIPS reporting in 2021 will be applicable to your Medicare reimbursements in 2023.

Due to the changes above, it is very important for you to develop a strong reporting plan for 2021. Carefully review the list of Quality measures that have been removed to find out if you have previously reported on these measures. If so, you will need to find Quality measures that work for you and your practice to replace the ones that have been removed. Fully reporting on all MIPS measures will be absolutely necessary to reach the minimum threshold of 60 points and avoid the 9% penalty for 2021. TriumpHealth’s well-trained MIPS consultants can create the best plan to help you reach your reporting goals and maximize revenue.

by Madison Ross – Healthcare Sales Representative | TriumpHealth