Learn to speak the Managed Care Language (101)

Healthcare flow of funds explained. Managed Care 101 for healthcare entrepreneurs seeking to do business in the California market. Session led by Alex Yarijanian, CEO Carenodes. The aim: providing healthcare entrepreneurs with a framework within which they will find their place in the business value chain.

Everyone should be able to walk out of this session feeling empowered by having learned the basic flow of funds (starting at the payer).

About this Event

Topics covered in this session are as follows:

1. Managed Care Mind

Managed care: ‘utilization management’
Payment: Volume shift to value
Quality (‘value’) measured
Patient experience
Clinical outcomes

2. Lines of Business aka ‘LOB’ (funding source)

Medicare (Traditional Medicare and Medicare Advantage, Parts ABCD)
Medicaid (managed Medicaid, state / federal, Medi-Cal)
Duals (Medicare and Medicaid beneficiaries)
Commercial (on exchange, off exchange)

3. Products (benefit designs)

The spectrum of products: HMO, PPO, POS, EPO, FFS
Business ramifications

4. Difference between ‘LOB’ vs ‘product’

Difference between ‘LOB‘ (Medicare, commercial, etc) vs ‘product‘ (HMO, PPO, etc.)

The video and article link below is of an expanded version of this training https://www.carenodes.com/healthcare-flow-of-funds-explained-healthcare-entrepreneur-bootcamp/

Don’t Lose Revenue With an Outdated Fee Schedule

If you have not updated your practice’s fee schedule for several years, you may be in for some surprises. Carenodes Advisory recommends that you analyze and update your fees annually to make sure they are higher than insurance allowables.

Remember, insurers typically will pay you either their allowable or your fee – whichever is lower. By charging less than the allowable, you are not getting the maximum reimbursement you are entitled to receive. If you are receiving 100 percent of your billed charge from a managed care plan, this could indicate your fee is set too low.

Many commercial plans base their fees on Medicare reimbursement, making it easier for you to evaluate their reimbursement patterns. As Medicare publishes its new fee schedule each year, you have an opportunity to compare your own fees against the new rates. At the same time, you can make revenue projections for the coming year and assess the value of your managed care contracts to your practice.

Rates: Health Behavior Assessment Services Assessment or Reassessment Reimbursement Table

Health Behavior Assessment Services Assessment or Reassessment Reimbursement Table

Health Behavior Assessment Services Assessment or reassessment Demystified

All providers should become familiar with the new codes so you know when and how to use them. Be sure you coordinate with your billing support or vendors, including your billing software vendor or Electronic Data Interchange (EDI) clearinghouse, to make sure they are ready.

CPT code 96156 is used to describe health behavior assessment, or re-assessment, that is conducted through health-focused clinical interviews, observation and clinical decision-making.
Assessment services are now event-based and CPT code 96156 is billed only once per day regardless of the amount of time required to complete the overall service.
Only report 96156 for assessment of a patient with a primary diagnosis that is physical in nature.

Do not report 96156 on the same day as psychiatric services (90785-90899) or adaptive behavior services (97151-97158, 0362T, 0373T).

For patients that require psychiatric services or adaptive behavior services, as well as health behavior assessment/intervention, report the
predominant service performed.

Evaluation and Management (E/M) services codes, including counseling risk factor reduction and behavior change intervention (99401-99412),
should not be reported on the same day as health behavior assessment and intervention codes by the same provider:
These services can occur and be reported on the same date of service as long as the E/M service (99401-99412) is performed by a physician or
other qualified health care professional (QHP) who may report evaluation and management services.
However, health behavior assessment and/or intervention services performed by a physician or other QHP who may report E/M services
should do so using codes found in the E/M Services or Preventive Medicine Services sections of the CPT® Manual.

Guidelines: Health and Behavior Assessment/Intervention services (96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171)

AMA Guidelines:

These codes are used to report services provided face-to-face by a physician or other qualified health care professional for the purpose of promoting health and preventing illness or injury. They are distinct from evaluation and management (E/M) services that may be reported separately when performed. Risk factor reduction services are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.
Preventive medicine counseling and risk factor reduction interventions will vary with age and should address such issues as family problems, diet and exercise, substance use, sexual practices, injury prevention, dental health, and diagnostic and laboratory test results available at the time of the encounter.
Behavior change interventions are for persons who have a behavior that is often considered an illness itself, such as tobacco use and addiction, substance abuse/misuse, or obesity. Behavior change services may be reported when performed as part of the treatment of condition(s) related to or potentially exacerbated by the behavior or when performed to change the harmful behavior that has not yet resulted in illness. Any E/M services reported on the same day must be distinct, and time spent providing these services may not be used as a basis for the E/M code selection. Behavior change services involve specific validated interventions of assessing readiness for change and barriers to change, advising a change in behavior, assisting by providing specific suggested actions and motivational counseling, and arranging for services and follow-up.
For counseling groups of patients with symptoms or established illness, use 99078.
Health and Behavior Assessment/Intervention services (96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171) should not be reported on the same day as codes 99401–99412.

Category: Fee Schedules