"Our goal was to develop a single source of truth that is user-friendly, dynamic, and easily accessible," said Jeannette Wood, vice president of revenue cycle management for Privia Health.
A rapidly changing situation like the COVID-19 pandemic calls for a dynamic solution for tracking billing and coding changes for virtual services from different payers across multiple states. That's why revenue cycle leaders from Privia Health, a national physician-led medical group, based in Arlington, Virginia, developed an online workbook that can be updated and shared in real time to manage those changes effectively across their multistate network.
"Our goal was to develop a single source of truth that is user-friendly, dynamic, and easily accessible," Wood said. "We also needed a solution that was not only flexible, with payer rules changing daily, but also scalable so all of our markets would have real-time information at their fingertips."
Privia uses G Suite, a cloud-computing resource from Google that enables productivity and collaboration tools, allowing the workbook to be scalable and sharable across its multistate network.
A special workgroup, with representatives from billing, coding, and payer contracting departments, works together to maintain accurate information by monitoring and validating updates from payers, and then incorporates those new details into the online workbook.
However, "the entire revenue cycle management [RCM], revenue integrity and coding teams also provide new information every day," Waller said. "We are using a shared Google drive, so all updates are real time."
Here are four critical attributes of the workbook:
1. Detailed: Inconsistencies between payers and different markets meant Privia Health's tool not only needed to be payer-specific, but also easy for the providers and RCM staff to navigate across markets.
Multiple tabs in the workbook aid in navigation and provide easy access to those details.
The first tab contains a table of contents linking to different sections of the workbook. It also notes the date that the workbook was last updated and includes a list of recent updates.
"For example, on 5/13, we learned that annual wellness visits can be done telephonically if a virtual visit fails," Waller said. That update was added to the workbook and noted in the table of contents.
The table of contents tab also contains workbook instructions; resources about diagnosis coding and compliance; and a list of CPT categories like evaluation and management (E/M), telephone services, behavioral health, and skilled nursing facility services.
2. Scalable: Privia Health has more than 2,500 providers in six states and the District of Columbia, and cares for 2.6 million patients across 660 care center locations, so tracking and disseminating daily changes requires both speed and precision.
That's why the workbook had to be scalable across all its markets. In addition to the table of contents, there are tabs for each market that contain CPT and HCPCS codes and full descriptors of each, including detailed information about what's allowed by each payer.
3. User-friendly: The table of contents contains links to different markets for each service, allowing users to access the correct section with one click.
Each of those sections is created in such a way that they are easy to navigate.
In a left-side column, users see the CPT and HCPCS codes and their descriptors that are allowed by CMS and commercial payers.
Payers are listed in columns across the top.
An X appears in a column if a payer doesn’t allow a code. There are also notes about point-of-service locations and modifiers; COVID and non-COVID cost-sharing waivers; and any specific payer coding or billing guidelines under the payer and CPT code, Waller said.
Codes that always seem to be problematic have a hyperlink leading to a one-page explainer.
It's also easy to check for updates, via both the table of contents and direct communications. "We instruct all users to check the updates daily," Waller said. "We can [also] send the workbook link directly to providers so they can have this information readily available."
4. Dynamic and flexible: "The workbook continues to evolve daily as we incorporate additional payer requirements and/or additional billing guidelines as they become available from the payers," Wood said.
The workgroup reviews payer communications for updates daily, and monitors denials, updating the workbook with that information, too. When new data is added to the workbook, the change is notated on the table of content.
These workbooks can also be flexible and helpful post-COVID.
"As we move out of the COVID crisis, we will continue to use this workbook to provide immediate updates on payer changes, such as when they will end the expanded COVID services and return to their normal telehealth policies," Wood said. "We also have specialty-specific workbooks that we are in the process of updating that we will share in the same manner."
Hallmarks of success
Using the workbook to monitor and track changes has allowed Privia Health's revenue cycle team to operate more efficiently.
"For example, we have seen payers change the place of service and/or modifier they want on the claim from one day to the next," she added.
Because they were tracking those changes using the workbook, Privia has been able to quickly make changes to its practice management system.
If new data changes how a claim needs to be submitted, "we can immediately create a rule that will hold the claims to ensure that the claim is submitted correctly," Wood said. The practice management system rule will hold claims for the correct place of service or modifier until those changes could be automated.
"By having a workbook that can be changed and immediately viewable by our network of care centers and RCM staff, everyone was alerted to the change and were able to correct the claims on hold without the need for additional communication."
Be sure to tune in to hear an in-depth discussion with Wood and Waller in an upcoming HealthLeaders Revenue Cycle Podcast, where they detail the workbook's creation, management, and usage, including practical tips for revenue cycle leaders to implement a similar tool within their own organizations.
Alexandra Wilson Pecci is an editor for HealthLeaders.