When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

What is “balance billing” (sometimes called “surprise billing”)?

In parts one and two of this multi-part blog series, we’ve gone over important information on PhyScore. Our patent-pending system for comprehensive evaluation of physician care, patient outcomes and costs within emergency department medical billing and other related areas, PhyScore contains several important factors that play a role in not only assessing physicians, but also assisting them with numerous practice and efficiency areas. 

The theme of big data has impacted numerous important industries, and the world of emergency department medical billing and coding is no exception. ER billing and various other medical billing areas have been enormously impacted by big data in a variety of ways. 

Released 4/10/2020

The government is providing direct support to healthcare providers fighting the COVID-19 pandemic. On March 27, 2020, the President signed the bipartisan CARES Act that provides $100 billion in relief funds to hospitals and other healthcare providers on the front lines of the coronavirus response. This funding will be used to support healthcare-related expenses or lost revenue attributable to COVID-19 and to ensure uninsured Americans can get testing and treatment for COVID-19.

A Message from Paul Orcutt, M.D., FACEP, PhyCon Chief Executive Officer

There are too many uncertainties to get the true information, rumors and consequences of the Covid-19 virus epidemic at this point, along with the passage of an 800-page bill by Congress. At this time, I would like to make one point that may save you and your hospital’s balance sheet.

CMS has promised the moon on COVID ED care, but they have not given a directive as just how this will happen.

Critical Care Coding

Challenges:

- Unexplained Low Collections
- Lack of Understanding of the documentation rules and their application of various critical care codes.
- Physician groups can have wide internal variances in critical care documentation because of complex usage criteria and lack of training

At PhyCon Incorporated, we’re proud to serve as the top choice in Emergency Department billing for clients throughout California, from medical billing solutions to coding and compliance areas that are vital for emergency rooms. We analyze everything from your medical billing records, to the profitability of your department.

When it comes to medical billing and coding, emergency rooms are often very different from other departments of a hospital. From the pace of day-to-day operations to the kinds of patients seen and frequency of visits from doctors, there are very different challenges when it comes to properly documenting emergency room visits and required payments. 

Business Situation 

Mid-sized CA hospital-based physician group 65k patient visits/year 

Challenges 

- Unexplained collections drop in biggest payer group – accounting for 30% of income 
- Looking for billing company with good reputation on collections and customer service 

Phycon Results 

Business Situation 
Large hospital-based physician group in South 
125k patient visits/year 

Challenges 
- Poor billing collection rate 
- Deficient billing operations with lost charts 
- Delayed billing resolutions 

Business Situation: 

Mid-sized hospital-based physician group in Southern CA 60k patient visits/year 

Challenges: 

- Due diligence on billing solution 
- Needed solution specific to emergency medicine 

Phycon Results:

- Increased revenue 20 percent in the first 6 months 
- Two year revenue increased over 25 percent. 
- No revenue loss in billing transition 
- Over $1 million more in first year collections 
- Customized Reports 
- Improved customer service

For any healthcare provider, there are usually two goals: Provide quality care to all patients based on their needs and run the most efficient practice possible without compromising patient care.  One of the largest potential obstacles that can happen with any practice is billing issues.  These could range from chasing down reimbursements to organizing and documenting a variety of different billing codes and functions. 

As we travel throughout this country providing documentation lectures to our physicians and clients, the most frequently asked questions are those concerning Critical Care documentation. Immediately when the physicians hear those words they crumble into a dearth of confounding confusion, and justifiable rage.
‘We’ve heard this lecture before and we still don’t get it!’ They know it is important because its lots of money lost. They have to listen to this menagerie of ifs, ands, & buts courtesy of the CMS abundant rules, exceptions and diverging scenarios committee.

Business Situation 
Midwest Urgent Care Facility 
60k patient visits/year 

Challenges 
- Fluxing monthly revenue 
- No accurate cash flow projections 
- Inconsistent customer service 

Phycon Results 
- Improved practice billing collections by 16 percent 
- More predictable revenue 
- Customized reports 

 Information Challenge 

Grading Physician Performance has long been a disorganized and incomplete science at best, more often fraught with inconsistency and biased opinions of the reviewer than actual ongoing hard data comparisons to support the reviewers’ conclusions. Many of these reviews are performed because the hospital or physicians groups are “required” to have them performed for “compliance,” “licensing,” or “unexpected” outcomes, therefore limiting the scope and purpose of a comprehensive performance review.

Critical care includes such a broad range of presentations in emergency medicine and sometimes these variable presentations are difficult to ascertain when comprehensive level 5 99285 care becomes critical care 99291.