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About Auctus

ELIGIBILITY CHECK

Before the patient is seen by the practice, ensuring that the patient has active coverage with their insurance plan AND that the provider accepts that insurance plan. This is the first line of defense against non- payment. If the patient is out-of-network (OON) with the provider or does not have active coverage, the claim may not be paid. IF the provider is not contracted, or is OON with all payers by design, this step can of course be overlooked.
Who usually does this? The office typically. Front desk for office visits/procedures versus surgical scheduling for major procedures. The patient shouldn’t be in front of the physician without eligibility being verified per visit. Don’t just check once; check before every visit. Many practices check 2-5 days ahead of each visit
How is this done? Most practice management (PM)/electronic medical record (EMR)/Billing Systems have an integrated solution with the Clearinghouse they partner with. In this way, the practice can run a batch/bulk check based on all the appointments for a day or date range, to get all responses back with a single click. Eligibility checks can also happen directly in the Clearinghouse, on payer portals such as Availity/Optum/ Cigna4HCP and/or there are a number of third party systems built for exclusively eligibility checks.
How often? We recommend checking at point of booking/scheduling if feasible as well as daily looking out at least two days. For example, check eligibility today for the patients coming in day after tomorrow so you give yourself enough time to problem solve.

PRIOR AUTHORIZATION

Check out our Auths Guide for more info, but essentially Auths are required for major surgical procedures to ensure medical necessity as defined by the payer. Think of this as a box to check before surgery can happen.
Who usually does this? Often in-house Medical Billers, surgery schedulers or even patient care coordinators get stuck with this job, when their time could better be spent on their primary job functions. The Auctus Group offers an Auths Service Line to offload the pain and suffering from our clients.
How is this done? Check out our Auths Guide. Waaaay too much to type. Long story short, using the PM/ EMR + payer portals + spreadsheets + follow up notes somewhere…all sorts of fun.
How often? Depends how busy you are Doc! Auths should be submitted as soon as the patient leaves the office if they’re a potential buyer so you can get them on the schedule. Volume is going to be dependent on how busy you are of course.

PRE-COLLECTION

If a patient is coming in office for a visit, be sure to collect that copay. It is also wise to check the patient ledger to see if they have an open balance from previous visits. Remember not to collect a copay for post-operative global visits usually within 10, 30, 90 days of a procedure depending on the type. For office procedures or surgeries may carry larger balances than copays due to deductible and coinsurance, which are extremely common on most insurance plans these days. By using the expected billable CPT codes and an eligibility check, one can estimate what the patient MAY owe after surgery and educate the patient to avoid surprises as well as collect the balance up front to avoid chasing on the back end.
Who usually does this? Copays land at the front desk/check-in. This should be the second step after verifying that the patient has coverage. Copay gets collected as the patient checks in for their visit or it will likely have to be invoiced after insurance processing on the back end, prolonging or even eliminating the payment altogether if that patient ignores the statement(s). Benefit Estimations are more commonly carried out by the billing department and/or authorizations representative. Collecting the balance is often best received at the pre-operative visit, when a practice representative can sit down with the patient and answer billing questions/discuss process as well as educate and collect…so it doesn’t feel like a shakedown. The Auctus Group provides Benefit Estimations as a part of our Auths Service Line. Every Auth comes with a Benny Estimate so the practice can leverage pre-collections and avoid patient statements, which often go unpaid.
How is this done? Copays are easy to collect and post into your PM/EMR. Same with the posting of the Benefit Estimation amounts. Collect the payment. Post it to the PM. Leave it unapplied as a credit until the insurance bill/claim processes. Now, how to get at that benefit estimation is a whole other process and really where the time suck comes in. In short, CPT allowable minus patient benefits equals what to collect. There’s a whole lot more math involved than that. Ask your friendly local Auctus Rep for more info.
How often? This should be done for all major surgical cases in an OR or Office Based Surgi-suite. SOME practices will attempt to run this process down for EVERY visit, which can prove a challenge without embedded technology. To pre-collect, you need the codes (AKA what services are being rendered) and the benefits. Part 2 is easy. Part 1 requires knowing what your MD is doing in the room with a patient…not always easy if it isn’t a major surgical case (so don’t beat yourself up about calculating a 99213 vs a 99214 allowable to collect on the way out the door at check out).

DOCUMENTATION

The most necessary of evils. No documentation, no billing. Sorry folks. This is a regulatory requirement for billing and a requirement for you MDs out there for other obvious reasons. This is the baseline and basis for billing, so be sure you document well. If it isn’t written down, we can’t bill for it…even if the procedure was conducted.
Who usually does this? Really? You really need to ask?
How is this done? In your EMR, unless you’re still on paper…please tell me you’re not still on paper.
How often? Daily. You do document every day right?

CODING

This is the first make/break moment in billing folks. We have minimized the practice of medicine to a series of five digit CPT codes. Yeah, yeah, yeah, we have ICD-10s and modifiers as well, which are certainly important, but using the science of CPTs with a bit of the art of coding is where a Medical Biller pulls their weight. Maximize the CPTs and leverage the proper techniques without bending/breaking rules or blurring lines and you can make your providers more money!
Who usually does this? The provider is ultimately responsible for their coding no matter who does it. Often times they actually take on the initial coding. Sometimes they leave it for their Medical Biller or coder. There is a fair amount of variability here. That said, we consider “best practice” to be collaboration between provider and Medical Biller/coder. Dialogue builds trust and understanding. We want to be sure we are coding to maximize revenue, within the level of comfort of our provider(s). We also want to be sure to let our providers know if something is “over the line.”
How is this done? With coding tools like AAPC books and/or their electronic tool Codify as well as the Auctus Aesthetico App! Once you’ve landed on the right codes, they are typically entered into the PM/EMR and/or on the operative note if the procedure is carried out at a hospital or Ambulatory Surgery Center (ASC) and documentation is required in their system. In these cases the data is manually transferred to the PM/ EMR at point of Charge Entry.
How often? Of course volume will drive this decision, but should be 24-48 hours from time of charge submission/coding at Auctus. If you send a batch of 50 op notes, might take a bit more. If you only see a few cases a month, might be weekly.

CODING REVIEW – Just as pivotal as coding and even more so if the provider is not fully engaged on coding to
begin with. For the record we’re not complaining! It is just of course pivotal to review coding when the coding may not be as accurate on the front end. This involves reviewing primarily CPTs as well as ICD-10s and appending modifiers as appropriate.
Who usually does this? The Medical Biller/coder of course if not your friendly neighborhood Auctus Revenue Cycle Manager (RCM)!
How is this done? In EMR/PM or alternatively on .pdf for documentation provided on paper.
How often? As above.

CHARGE ENTRY

So services have been rendered, documented, are coded properly…now to get it entered into a system so you can generate a charge/bill. If it were the early 90s, we’d be talking about filling out a HCFA 1500 form or a UB. Given we are in the age of computers, nearly all providers are on EMR/PM systems, most often a single integrated system, although sometimes they can be split. At the Auctus Group, we always prefer to work in our clients’ system(s) so they own the data, have full transparency, and ultimately control. Charge entry involves ensuring that all patient demographics, insurance information, codes, coding information such as Place of Service (POS) codes, referring providers, NPI/Tax ID Number (TIN) identifiers, taxonomy codes, addresses and so on are properly loaded into the charge. Other specialty services such as facility bills require revenue codes, or anesthesia services require Base Units, and/or even drug codes (J Codes) require National Drug Codes or NDCs. Charge entry is really about ensuring that the claim is ready to go out the door with the most important part being that they have the appropriate fees/coding and are ready to be paid as quickly/cleanly as possible.
Who usually does this? Medical Billers are responsible for entering and validating charges once they’ve been coded. There is coding involved here in that you need to understand coding fully to successfully enter charges, but because notes are not being coded at this step a Medical Biller rather than an RCM may often enter charges.
How is this done? In the EMR/PM system of the provider’s choosing/use. These systems have a charge entry
workflow and module for specifically this process, which ties to the patient ledger so at any point in time one can run reports and/or view the charges for a given patient to see where the claim is at (e.g., has it been entered and/or submitted). Any errors are reported, which can be immediately corrected within platform to ensure a clean claim is submitted to payers.
How often? Should be 24-48 hours from receipt of charge from the MD with Auctus. Make sure you’re AT LEAST getting your claims out weekly please. Probably best to do it daily if you can. Think about it this way. Money will follow the Charge Entry Flow. You skip a few weeks…no problem…expect a break in revenue in 2-3 weeks for however long you skipped on charge entry for. Just don’t complain about it when it happens!
CLAIM SCRUBBING – This step involves system specific edits that “scrub” claims for missing data fields and/or data mismatches. Think of this as an automated system tool to run behind the human eyes at Charge Entry and ensure the proper information is on the claim to process. This DOES NOT scrub for coding or more complex billing idiosyncrasies, more system setup and field mapping as well as data completion.
Who usually does this? The Medical Biller will complete this task utilizing the EMR/PM tools at hand. RCMs do also submit claim batches occasionally in which case they would be responsible. Essentially this step MUST be completed as the part of entering any charge batch. The batch is not considered complete until it is coded, entered, scrubbed and submitted.
How is this done? Same place as the last step. EMR/PM of the provider’s choosing/use. Typically, once charges are entered, they are pushed to a scrubbing queue. Typically systems will require a system scrub PRIOR to allowing submission and/or the Medical Biller must override the warning/reminder to scrub. Natural scrubbing is of course done at charge entry, but this is a more systemized/system driven process. Click the button, get back the errors, fix the errors, send again…all at once…don’t submit, get errors and wait ‘til tomorrow…that would be a waste of time. Common errors include name mismatches, missing insurance ID or group number, missing DOB, NCCI edits (if programed) and so on…the simple stuff.
How often? Per charge entry batch. This happens after you enter charges – every time.

CLAIM SUBMISSION

This is where the magic happens! The claims actually get sent OUT of the EMR/PM and to the payers via the clearinghouse (think electronic USPS or pipe to the payers that your encrypted claims data runs through).
Who usually does this? We have the same person who enters the charges, scrub and submit them…because why split the workflow. This is typically a Medical Biller, but could also be an RCM.
How is this done? Typically it is no more than the click of a button. SOME systems (more old-school) will have you download and upload files from your PM/EMR to the clearinghouse manually, but this is rare these days. So click the button and off we go!
How often? As above.

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