1 EHR Identification: Using the EHR system discussed in the previous Informatics Project paper, discuss why the system is best for your business
2 Promoting Interoperability: Identify the type of healthcare reimbursement methodology your EHR will focus on. Discuss how the EHR will specifically address EACH component of interoperability.
3 Billing and Coding: Discuss in detail how your EHR will maximize feasibility for billing and coding for reimbursement. BE VERY SPECIFIC referencing various CPT and HCPCS codes most pertinent to your business. Discuss how your EHR can minimize CERT errors thus reducing the risk of RAC audits.
4 Voluntary Health Insurance Plans: Discuss how your EHR will better enable proper precertification of services, prior approvals, consideration for healthcare providers to prescribe medications best tailored to their insurance plans while meeting the standard of care, claim submissions and explanation of benefits.
5 Government-Sponsored Health Plans: Discuss IN GREAT DETAIL how your EHR will best coordinate with the requirements and regulations set forth by government- sponsored health plans (Medicare, Medicaid/CHIP, Tricare, VA healthcare, Indian Health Service, workers compensation, CHAMP VA and managed care plans.
6 Revenue and Reimbursement: Discuss SPECIFICALLY how your EHR will better enable your business to recoup revenue and maximize reimbursement costs.
7 Value-Based Purchasing: Discuss how your EHR will best enable your business to be accountable in regards to value- based purchasing.
8 APA: Correct APA formatting (one-point deduction per APA formatting error). Maximum page limit: 5 pages.
This information is based on a Family Medicine Clinic for Nurse Practitioners. For my EHR I used AdvancedMd. If I need to email it to please reach out and let me know. At the clinic I currently work at we use a lot of these CPT codes for urinalysis, flu, covid, strep, cbc, cmp, hga1c, Lipids, BMP, TSH, T4, sexual disease testing, pap smear and etc.
Healthcare Reimbursement Assignment
Student’s Name
Institutional Affiliations
Healthcare Reimbursement Assignment
Health systems have seen rapid adoption of electronic health record (EHR) technologies such as AdvancedMD in the recent past. The use of AdvancedMD in the healthcare delivery process is associated with numerous benefits (AdvancedMD, 2021a). Some of the benefits include timely communication among healthcare providers, efficient decision-making by busy healthcare providers, reduced rates of medical errors, increased patient engagement, and speedy access to crucial health information (Glauser, 2016). One of the reasons why today’s health systems integrate AdvancedMD is to enhance healthcare reimbursement (AdvancedMD, 2021a). This assignment will explore how AdvancedMD promotes interoperability, promotes billing and coding, enhances both voluntary and government-sponsored health insurance plans, enables revenue and reimbursement, and promotes value-based purchasing.
EHR Identification
AdvancedMD is the best for the business because the facility urgently needs a medical management technology that promotes effective billing, coding, and reimbursement. One of the features that make the technology appropriate for the organization is that it allows the management of multiple providers at a time from different locations (AdvancedMD, 2021a). The specific components of AdvancedMD that make it useful as medical management software for the organization include; a platform for practice management, digitalized patient information in the form of electronic health records, billing, tools that facilitate patient engagement, a functionality for telemedicine, patient charts, financial analytics tools, and business intelligence reporting (AdvancedMD, 2021a). Due to these components, AdvancedMD will enable the organization to bring providers together and tailor their practices to the desired workflow.
Promoting Interoperability
AdvancedMD will promote interoperability by allowing applications and devices to access, integrate, and exchange data in a coordinated manner thereby enhancing the implementation of the reimbursement methodology. The healthcare reimbursement methodology that AdvancedMD will focus on is value-based reimbursement. The organization prioritizes value in healthcare delivery. Therefore, value-based reimbursement will enable it to pay providers based on the quality of care that they provide rather than the quantity (Reiter, 2016). AdvancedMD will enable the organization to extract actionable data to facilitate the reimbursement process.
AdvancedMD will address each component of interoperability thereby promoting effective use. According to the Healthcare Information and Management Systems Society (HIMSS) (2021), the four levels or components of interoperability that healthcare technology tools are required to meet include; foundational, structural, semantic, and organizational components. The foundational component encompasses the interconnectivity requirement that applications must meet to effectively send and receive data. AdvancedMD will meet this component through its ‘patient encounter’ feature that supports electronic communication connectivity (Uzialko, 2021). According to HIMSS (2021), the structural interoperability component of a healthcare technology tool refers to the syntax and format as well as the manner in which data exchange and data fields are organized to enhance data interpretation. AdvancedMD will address the structural component through the use of a user-friendly interface that can easily be navigated by users (Uzialko, 2021).
EHR technology normally utilizes unique vocabularies that provide shared meaning and understanding to the users while at the same time maintaining adherence to applicable laws and regulations. The semantic component of interoperability entails the use of standardized and publicly known vocabularies and data sets to ensure data codification (HIMSS, 2021). AdvancedMD will address this component through the use of in-built software that includes CPT code libraries and ICD-10 codes (Uzialko, 2021). AdvancedMD will also address the organizational component of interoperability. The organizational component encompasses the governance, policy, social, legal, and organizational considerations that must be met to ensure data security as well as a consent-supported and timely exchange of information (HIMSS, 2021). AdvancedMD will address this component by ensuring that the system adheres to Health Information Technology for Economic and Clinical Health (HITECH), Health Insurance Portability and Accountability Act (HIPAA), American Recovery and Reinvestment Act (ARRA), and the National Institute of Standards and Technology (NIST) requirements (Uzialko, 2021). By addressing each of the four components of interoperability, AdvancedMD will allow appropriate as well as secure access and sharing of data across a wide spectrum of care that is coordinated by multiple providers.
Billing and Coding
Billing and coding will enhance the billing cycle that the new system will use to facilitate effective reimbursement. For example, the system will use medical billing to prepare bills and insurance claims for patients. Additionally, medical coding will enable the system to extract relevant information from clinical documents and health records for billing purposes (Lee & Choi, 2021). To maximize feasibility for billing and coding for reimbursement, AdvancedMD will utilize CPT, ICD-10, and HCPCS codes for the healthcare services that are provided by the organization. The specific CPT, ICD-10, and HCPCS codes that the system will create will be those for urinalysis, flu, covid-19, strep, complete blood count (CBC), CMP, hgA1c, lipids, BMP, TSH, T4, sexual disease testing, and pap smear. Essentially, AdvancedMD can minimize Comprehensive Error Rate Testing (CERT) errors by preventing duplication of tests and minimizing unnecessary ones through enhanced patient identification. The technology can also identify programs that are likely to attract improper payments (Centers for Medicare & Medicaid Services, 2021). This helps to reduce the risk of recovery audit contractor (RAC) audits.
Voluntary Health Insurance Plans
AdvancedMD will enable the organization to manage voluntary insurance plans and reimbursements associated with them. For example, to better enable proper precertification and prior approval of services, the technology will utilize an in-built system to determine whether specific treatment interventions or prescription drugs that a client wants to include in the plan are medically necessary (AdvancedMD Inc., 2021). The system will be able to certify and approve treatments and prescription drugs that are medically essential. Due to its enhanced interoperability, AdvancedMD will enable healthcare providers to prescribe medications best tailored to the certified and approved insurance plans while at the same time meeting the standard of care, claim submissions, and explanation of benefits (AdvancedMD Inc., 2021).
Government-Sponsored Health Plans
AdvancedMD will coordinate with the requirements and regulations set forth by the government-sponsored health plans. Examples of plans with which it will ensure effective coordination include; Medicare, Medicaid/CHIP, Tricare, VA healthcare, Indian Health Service, workers compensation, CHAMP VA, and managed care plans (Centers for Medicare & Medicaid Services, 2021). Precisely, the technology will adhere to the regulations that define the effective use of these health plans when making reimbursement decisions.
Precisely, AdvancedMD will integrate the requirements are rules for individual plans to ensure effective use and reimbursement. For example, important Medicare and Medicaid/CHIP requirements that the technology will integrate are designing the Subscriber, Insurance, and Responsible Party screens to enable users to enter details regarding the subscriber ID and date of birth. (AdvancedMD, 2016). These considerations enhance the system’s ability to check the insurance eligibility of a patient thereby reducing chances of eligibility rejection.
AdvancedMD technology will enable the organization to improve AR management with Tricare, VA Healthcare, and CHAMP VA plans. These government insurance plans require healthcare organizations to initiate AR telephone calls with insurance companies to request claim status with details regarding outstanding balances on patients’ accounts before taking necessary actions. The AdvancedMD will meet this requirement and facilitate the entire process for enhanced billing and reimbursement (BillingParadise, 2021a, BillingParadise, 2021b). The Indian Health Service requires tribal health software to effectively meet the demands of its Resource and Patient Management System (RPMS). AdvancedMD will provide this software for enhanced performance (AdvancedMD, 2021b). Again, in managed care plans and workers compensations, AdvancedMD will utilize its medical billing software to track patient care episodes and the nature of services provided to patients thereby ensuring effective revenue cycle management (AdvancedMD, 2021a).
An important regulation that has been set forth to govern healthcare service delivery with government-sponsored health plans is the “Right of Access Rule” under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). As an electronic health records (EHR) technology, AdvancedMD will adhere to the Right of Access Rule as defined in the HIPAA and as required by the government-insured health plans. According to Brody (2020), the Right of Access Rule requires all entities that are covered by HIPAA to allow patients to access their medical records as soon as possible upon request. The requested information must be provided within 30 days of the request. AdvancedMD will honor this request by allowing patients covered by various government-sponsored health plans who have requested to be allowed to access their medical records to access the information not later than 30 days after the request (Brody, 2020). When doing so, AdvancedMD will ensure effective authentication of patients to avoid security and privacy breaches.
Revenue and Reimbursement
Businesses should always strive to maximize reimbursement and increase revenue by keeping costs low. One of the strategies to employ is to establish a clear collection process using a well-thought-of pricing technique (Reiter, 2016). Specifically, AdvancedMD will better enable the business to recoup revenue and maximize reimbursement costs using both the per-provider model paid monthly and an encounter-based model paid at the time of patient encounter (Uzialko, 2021). These reimbursements will only be made when the services offered by providers meet the desired quality standards.
Value-Based Purchasing
AdvancedMD will enable the business to be accountable in regard to value-based purchasing in various ways. Precisely, the technology will determine payments based on how closely the providers followed best clinical practices, how well the services provided enhanced patients’ care experiences, how well they achieved quality goals, and how much particular services improved on each measure compared to their performance during a given baseline period (Reiter, 2016). Notably, AdvancedMD is able to extract data that it can use to track and compare quality metrics and measures.
Conclusion
A healthcare organization that needs a medical management technology that promotes effective billing, coding, and reimbursement should consider integrating AdvancedMD. Features of AdvancedMD enable it to promote interoperability, promote billing and coding, enhance both voluntary and government-sponsored health insurance plans, enable revenue and reimbursement, and promote value-based purchasing. When integrating the technology, an organization must ensure that it meets all the four levels of interoperability for enhance performance.
References
AdvancedMD. (2016). Medicare requirements for eligibility. https://www.advancedmd.com/company/new-products-features/medicare-requirements-eligibility/
AdvancedMD Inc. (2021). Medical billing wholesalers. https://www.advancedmd.com/advancedbiller-marketplace/medical-billing-wholesalers/
AdvancedMD. (2021a). AdvancedMD: Practice, on the cloud. https://www.advancedmd.com/
AdvancedMD. (2021b). Tribal health completely within the cloud. https://www.advancedmd.com/tribal-health/
BillingParadise. (2021a). AdvancedMD: AR calling support. https://www.billingparadise.com/AdvancedMD/ar-calling.html
BillingParadise. (2021b). Tricare AR management service. https://www.billingparadise.com/tricare/ar-management-service/
Brody, M. (2020). Right of access rule and HIPAA. https://www.advancedmd.com/blog/right-access-rule-hipaa/
Centers for Medicare & Medicaid Services. (2021). Comprehensive Error Rate Testing (CERT) Program. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/IntroductiontoComprehensiveErrorRateTesting.pdf
Lee, J., & Choi, J. Y. (2021). Improved efficiency of coding systems with health information technology. Scientific Reports, 11(1), 10294. https://doi.org/10.1038/s41598-021-89869-y
Glauser, A. (2016). Data Re-Use: Usability, patient safety & organizational policy. https://www.advancedmd.com/blog/data-re-use-usability-patient-safety-organizational-policy-2/
Healthcare Information and Management Systems Society (HIMSS). (2021). Interoperability in healthcare. https://www.himss.org/resources/interoperability-healthcare
Reiter, G. (2016). Healthcare insurance and reimbursement methodologies. https://account.ache.org/eweb/upload/GapenskiReiter_chapter2-2acdcc36.pdf
Uzialko, A. (2021). AdvancedMD review. https://www.business.com/reviews/advancedmd-electronic-medical-records-emr/