Optimizing Business Processes for Telehealth Services | DMJ & Co., PLLC

The COVID-19 crisis saw the rapid adoption of telehealth services that enable healthcare providers to use technology and electronic information to safely see their patients. Telehealth providers can remotely diagnose, treat, and monitor patients who otherwise are unable to receive in-person medical care. They connect with their patients through the internet, video conferencing, streaming video, imaging, telephone calls, and other electronic communications. Patients enjoy the safety and flexibility that telehealth provides for both routine and chronic care.

Now that the initial rush has passed, many providers are beginning to evaluate whether the telehealth business processes and policies they quickly put in place are effective for optimizing reimbursement opportunities and reducing compliance and privacy risks. Many telehealth providers have experienced lost charges, lower than expected reimbursements and denials for untimely filing, coding errors, incompatible services and lack of coverage, all of which affect the financial well-being of their practices. Many providers also may be subject to retroactive audits of their coding and medical record documentation for telehealth services.

Establishing Sound Business Practices for Telehealth

Due to the rapid tide of the pandemic, some telehealth providers didn’t have the time and resources needed to develop the proper workflow, policies, procedures, and controls necessary to sustain telehealth in the long run. Even those providers who took additional time to implement telehealth have struggled with finding ways to improve their telehealth business operations and functions.

Telehealth is likely to remain a significant channel of healthcare delivery well beyond the pandemic. Providers should analyze the effectiveness of their current policies, procedures, systems, and controls to refine their operations, maximize financial opportunities, and reduce risks.

A comprehensive set of policies, procedures, and controls, separate from those used for traditional service delivery, is foundational to establishing a long-term telehealth program. This business framework should be separate and designed specifically for telehealth services rather than added on to those used for traditional office visits.

Focusing on the Accuracy of Coding and Billing

Many providers have experienced denials for telehealth services after the fact. Procedures should be implemented and monitored to ensure the accurate use of billing codes and the timely processing of billable services, remittances and claims follow-up. A provider’s telehealth policy should require that coverage verification must be completed with the patient’s payer before the first telehealth visit, which will result in fewer denials and higher reimbursements.

It’s important for business office staff to be knowledgeable about each payer’s specific requirements for coding and billing. Medicare and commercial payers often require the use of different Common Procedural Terminology (CPT) Codes for the same telehealth services provided, making coding and billing complex. For example, Medicare maintains a large list of eligible CPT codes, while some private payers prefer the use of a single telehealth code instead. The accurate use of service codes and billing modifiers ensures that a claim will be paid. The documentation of medical necessity is critical for telehealth claims, as is documentation under the principles of evaluation and management (E/M) coding.

Healthcare providers should perform quality control audits for coding to ensure compliance and address lost revenue issues. For example, telehealth bills may have been “under-coded” based on a lack of understanding of the guidelines or the different payer requirements. These audits highlight problem areas and provide opportunities to initiate process improvements.

Many commercial payers have different requirements for submitting bills for telehealth services than for traditional office visits and they often change their telehealth billing requirements on short notice. Therefore, it is important for staff to visit payers’ websites frequently to closely monitor their evolving requirements and remain up-to-date with payer correspondence.

Improving Charge Capture

Healthcare providers can use various tools to analyze unbilled telehealth visits and reconcile the number of scheduled sessions with the number of sessions actually billed, complete with explanations for canceled, no-show or unbilled sessions. These tools can help staff ensure all unbilled charges are captured and resolved in a timely manner to avoid denials due to late billing.

Charge capture tools can estimate the amount of reimbursement expected from each payer for each telehealth session. Because many payers have telehealth rates in effect for a limited amount of time during the pandemic, these expected payment amounts should be monitored and adjusted frequently to provide accurate cash flow projections. Staff should investigate discrepancies in the amounts received against estimated reimbursements. Providers also can use benchmarks to develop expectations for telehealth reimbursements and better understand the reasons why average reimbursement may differ from the relevant benchmarks.

Overcoming Denials

Because payers view telehealth services differently than in-person services, healthcare providers should establish a separate telehealth denials management program. The goal of the program should be to recover bills that have already been denied and to identify their root causes to prevent similar denials in the future. A sound telehealth denials management program should include:

  • Compilation of telehealth denials
  • Denials tracking and trends
  • Recommendations for remediation of specific denial reasons through process improvements or education
  • Tracking claim recovery results by denial rate and turnover rate
  • Reporting functions for claims recovery results
  • Ongoing processes to capture prospective prevention results

Maintaining Patient Privacy and Reducing Risks

In the rush to provide telehealth services online, many providers were at increased risk for cybersecurity breaches and violations of patients’ privacy under the Health Insurance Portability and Accountability Act (HIPAA). Stay-at-home orders in several states forced some providers to work from home on personal computers with limited security protocols in place. This left them and their patients vulnerable to cybersecurity breaches and theft of Protected Health Information (PHI).

Healthcare providers should actively engage their organization’s information technology (IT) professionals to ensure appropriate cybersecurity protocols and procedures are in place to reduce the risk of security breaches and violations. Security software, secure remote access to internal healthcare systems, and the use of virtual private networks can help providers maintain secure connections and protect their patients and their practices from security breaches and privacy violations.

Please contact DMJ Healthcare Consulting to discuss this further.



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