There are several scenarios in which ordering entities, such as physician practices, want other healthcare providers, like laboratories or medical device companies, to bill them for services performed or devices delivered rather than billing payors or patients. For example, if a diagnostic provider offers only non-covered services, such as a new genetic test or novel medical device, the ordering physician may set a policy that states payors should never be billed. Likewise, the ordering physician’s office may prohibit billing patients directly, due to a higher likelihood of non-payment and thus write-off. In both cases, flexible client billing rules and e-invoicing are required.
Sometimes, clients (i.e., ordering entities) want more control over the billing process and what is billed to patients. For example, if a client/physician office serves an indigent population or many uninsured patients, it may be able to offer approved discounts for certain services prior to billing patients. In these cases, an RCM solution should provide the ability to:
XIFIN RPM provides the flexibility needed for clients to configure billing rules to suit their preferences. The underlying functionality and process is the same regardless of whether your business is a laboratory, community oncology clinic, pathology practice, medical device company, or nursing home. Yet the XIFIN RPM solution also supports unique workflow or business requirements for different diagnostic modalities or physician group specialties.
For example, any type of service can be flagged for automated client e-billing, based on “Test ID/Service ID.” The “Client ID” can also be used to automate client billing. In the XIFIN Client Portal, there is also a “Billing Assignment” tab. Clients open the portal, select the “Billing Assignment” tab and choose how to bill a particular service. Claims can also be split with certain line items billing to the patient’s payor and others to the client.
Billing rules can be configured at varying levels of granularity based on the wishes of the client. For example, a client may choose to bill everything to the payor except for:
- Certain patients
- Certain tests, procedures, or encounters
- Certain payors
- Any combination of the above
Nursing Home Specific Invoicing Capabilities
Nursing homes provide an excellent example for why flexible e-invoicing and billing assignment are valuable capabilities. Most nursing home residents have both Medicare Part A (hospital insurance) and Medicare Part B (medical insurance, including routine doctor’s care). The nursing home keeps a census that documents the services required by each resident each day. For example, the nursing home staff takes note in the census of time periods when a resident requires a higher level of skilled nursing, which may be covered under a Medicare Part A plan as opposed to a Part B plan. Therefore, each month a client-designated staff member logs in to the XIFIN Client Portal and conducts billing assignment at a line-item basis.
Medical Device Specific Invoicing Functionality
There’s a similar situation possible with medical devices and remote patient monitoring. Say an encounter comes in with a line item for the medical device itself and another line item for that month’s monitoring services. If the patient’s insurance plan covers the device itself but not the monitoring subscription, the claim may be split, and the client billing rules are followed to bill the device to the patient’s payor and the monitoring service to the client or patient directly. The ability to customize client billing rules based on several parameters enables clients to control which party is billed for each service performed.
Bills can also be split or redirected based on the client billing rules. For example, if a claim includes a specific combination of payor group (e.g., Blue Cross/Blue Shield) and service code, those charges can be redirected to one specific payor group member, based on billing rules. In another example, if a physician group has multiple locations, client billing rules can be set so that any charges for a certain service type get charged to one specific client ID representing a specific location.
Pricing configuration can be established in XIFIN RPM as well. For instance, based on client billing rules, a client may override the payor that is reported from an external interface, changing it to client billing. Payor exclusions can also be made. If an encounter comes in for a patient with coverage from one of the excluded payors, a client payor exclusion error is produced, and the claim is routed to error processing to be resolved.
Clearly, flexible client billing rules and e-invoicing make a tremendous impact on a client’s ability to control to which organization specific charges are billed. XIFIN RPM provides the flexibility to define third-party payor versus client/physician, versus patient billing based on a nearly unlimited combination of client, client type, payor type, service code, type of provider, and more. This creates the ability for each client to adapt its billing rules to its specific needs.
Having control over who can access and see information is critical. Client Administrators can set permissions establishing how much patient-level detail each member of the client’s staff can view. For example, it is generally unnecessary for an accounts payable clerk to access any patient-specific data, particularly any PHI, so the clerk can be limited to see basic accounting-related information only. A similar scenario applies for staff working billing errors or denials. Their view of PHI would also likely be limited by rules configured by the Client Administrator.
To learn more about the value of flexible e-invoicing capabilities and client billing rules, request a meeting today.Contact Us