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A snapshot of medical billing for speech therapists in the US

Medical billing for speech therapists is the process of confirming speech therapy benefits and requirements for authorization and creating healthcare claims to be submitted to insurance companies in order to receive payment for medical services rendered.

The medical billing revenue cycle is quite complex and, if not managed correctly, could have negative financial implications for healthcare organizations. Due to its complexity, many small to medium medical practices experience challenges in optimizing the medical billing processes, especially when scaling the business.

This article serves as a guide to better understanding medical billing for speech therapists and showcases opportunities to improve revenue growth.

Medical coding and medical billing for speech therapists

Medical billing and coding, although related, are two separate functions. In small organizations, these jobs might be handled by a single individual, but in most cases, these responsibilities are assigned to different people.  

Medical coding 

Medical coders use the information from a patient’s medical record, such as chart notes, x-ray reports, laboratory reports, etc., to identify the specific services the patient received. CPT codes need to be looked up first based on the service provided. These can be looked up on the CMS website. Then appropriate diagnosis or DX codes (based on why the patient needs therapy) and modifiers need to be added.  

Standard universal codes are then assigned to each procedure or service using CPT, and HCPCS codes are assigned. The diagnoses, in other words, DX codes, are identified using ICD-10 codes.  

These codes are needed so that the insurance company can confirm and pay the claims. Errors in coding can lead to claim denials and then needs to be corrected and submitted once more. Improper coding slows down the billing process and has a direct effect on the revenue of the business.  

Medical billing codes change constantly, and codes are frequently deleted or added. If you want to learn more about codes for speech-language therapy, we highly recommend reading our article dedicated to speech therapy billing and coding and bookmarking the CMS page for Coding guidelines. 

Medical billing 

Medical billers work between patients, providers, and insurance companies with the primary objective of ensuring proper reimbursement of services provided. Medical billing and coding meet each other where the codes are generated. Before a medical billing and coding process, a biller or coder needs to set up the EMR/Billing software with the appropriate CPT codes and fee schedules. They also add the most frequently used diagnosis codes to the billing system for the therapist to choose for each patient’s treatment plan.  

Once the setup is completed, medical coders need to check and confirm if each claim has the appropriate coding (CPT/Modifier/Diagnosis) appended to each claim before the claim is submitted. This will increase the possibility of sending a crisp, clean claim out. There are two stages for billing, which are front-end and back-end billing. Front-end billing tasks need to be completed before the speech-language pathologist, or other providers see the patient. Since the start of 2022, this stage has become more complex, thanks to the No Surprises Act. But more about that in the next section.  

Back-end billing occurs after the patient receives SLP services or other medical care. The medical coder assigns the appropriate codes and then hands them to the billing staff. The rest of the process is non-patient-facing, and therefore the term back-end is used.

Medical billing and federal laws

Medical billing used to be done on paper back in the day. But in October 2003, Congress mandated that providers submit electronic claims for payment. This was called the Administrative Simplification Compliance Act.  

This paved the way for new medical billing processes, software development for medical billing, clearinghouses, and more. But that certainly wasn’t the last federal intervention. New laws and acts arise frequently, the most significant recent one being the No Surprises Act of 2022. 

The No Surprises Act, or NSA, is a federal act that covers all states and is meant to supplement instead of replace other state-specific patient protection laws. In short, the NSA aims to protect consumers from surprise bills arising from medical care. But the implications apply to front-end and back-end billing stages. 

Non-compliance can lead to penalties of up to $10,000, so it is best to ensure that you comply with all the requirements of the No Surprises Act. We highly recommend reading our article dedicated to the impact of the No Surprises Act on the medical billing process 

The medical billing process

From first client contact to full reimbursement can take anything from days to months. Various factors contribute to this timespan, but the most significant contributor to delays is improper claims submissions, and it can already happen at the front-end stage of billing.  

Pre-Registration and Registration 

As mentioned before, the billing process starts when the patient contacts the practice for the first time. Here the patient’s demographic information is collected as well as insurance information.  

It is vital to avoid errors during this data capturing stage of the billing process. Simple demographic errors frequently. The patient’s first and last names are switched, spelling errors occur, or other such human errors.  

These tiny errors sometimes go through all the stages of the billing process and find their way to the clearinghouses, who then pick up the error and deny the claim. Now, the resubmission process starts, and the whole process is slowed down.  

Insurance  Eligibility and Authorization Verification 

Previously, the patient was supposed to make sure if a speech therapist is an in-network provider or not, but that has changed since the implementation of the NSA was mentioned in the previous section. 

The onus is now on speech therapy clinics to make sure that the prospective client is adequately covered. The prospective patient should be informed in writing of any inadequacies, and surprise billing could lead to penalties.  

Point of service collections 

The point of service is vital to the billing process. During check-in or check-out, billers can collect copay, deductibles, or the full balance. Getting it right the first time saves time and money as it prevents patient follow-up later. 

Encounter Form Generation 

An encounter form is also known as a fee ticket or superbill. It is generated during each patient visit and includes demographics, services that sometimes include codes, as well as clinician notes. After the visit, the provider will tick the boxes and sign the form to confirm that the services can be billed. This could also be done electronically on an electronic health record (EHR). 

Check-out 

This is the last point of the front-end billing stage and the start of the back-end billing stage. The encounter form should be complete, fees collected if need be and a follow-up appointment scheduled if required. 

If they weren’t involved before, this is the point where coders use the medical records to create codes for billing purposes.   

Services review process 

The charge entry staff uses the information on the encounter form and enters it into the practice management system, along with payment information from check-in or check-out.  

Charge entry staff double-check to see if all the relevant information is on the encounter form. They also need to contact the provider if they omitted information such as diagnoses information. 

Claim Generation 

Billing billers prepare the claim by pulling information from the encounter form or superbill. This could be done manually or electronically.  

Apart from patient and procedure information, additional info regarding the service provider such as name, location, signature, NPIs, and more. If you need more information about NPIs, we highly recommend watching our video explaining the different types of NPIs.  

The CMS-1500, also known as the HCFA 1500 form, is used by medical service providers to claim for medical services rendered.  

Scrubbing and submitting claims 

This part of the process refers to inspecting and clearing the claims of errors. This is done by billers using software or sent to a clearinghouse.  

Billers can submit claims directly to payers using HIPAA-compliant software, but the majority of offices use clearinghouses. The clearinghouse checks for errors and, if there are non, submits it to the payer. If errors are detected, the claim is delayed and sent back for corrections. Many offices don’t pay attention, and the rejections are not worked for months. Leading to timely filling or delayed payments.  

Tracking claims 

Tracking claims is essential to speed up the payment process and should be done daily. Clearinghouses provide dashboards that provide status updates for billers to monitor. After the payer receives the claim, the adjudication process commences. 

The adjudication process refers to the review process of insurers. It entails the outcome of whether a claim should be paid and how much would be paid. After this process, the payers generate Electronic Remittance Advice (ERA) statements for providers and Explanation of Benefits (EOB) statements for patients.  

ERA forms include the details of the payment or reasons why a claim was denied.  

Payment Posting 

After receiving ERAs, billing staff must post payments and match the patient accounts to the payments received. This reconciliation process is necessary to make sure that no errors slipped in along the way and that the correct amount was received.  

Patient Payments 

Patient statements are sent after remittance advice is posted. Patient statements should include dates, services performed, insurance claims paid, payments received during visits, and an explanation of the outstanding balance.  

Once payments are received, they should be posted and the accounts balanced. This is usually the end of the billing process, but not always.  

Denial Management 

Sometimes, payers deny claims, and billers should get to work as soon as possible. The remittance advice provides denial codes and explanations which the billers can use to commence mitigation procedures. 

If it is a data problem, coders and billers team up to get to the root of the problem, which could be missing or erroneous data. Alternatively, billers could appeal the denial.  

Accounts Receivable Collections and Credit Balances 

For a myriad of reasons, patients may fail to pay their final account, and billers need to follow up to ensure that the accounts don’t remain delinquent.  

Follow-ups need to occur, and if need be, conveniences such as payment plans could be offered. Once payments are received, billers can submit the payment to accounts receivable management.  

Credit balances need to be investigated and resolved as soon as possible. Suppose more money is received than what should have been paid. In that case, billers need to investigate and repay the funds correctly soon as possible. If they fail to do so, it could lead to lawsuits and penalties.

Optimizing medical billing for speech therapists: MPM or MSO

Medical practice management (MPM) software takes care of administrative and financial tasks in practices. It integrates scheduling, EHR, billing, and patient management software into one system.  

A medical management services organization (MSO) offers management support services that include the above-mentioned and more, including marketing and accounting services.  

So which one should speech therapist clinics invest in?  

Reporting 

Although software can do a lot to expedite the process in billing claims and to make every transaction paperless, this does not mean that the software can operate without human help. This is where the managerial and financial expertise of MSOs comes into play.  

Certain reports cannot be created by MPM software, even if it has a built-in data generator. These are unique reports and depend on the services that the provider offers. For example, a new set of treatments has been added, and the doctor would like to know which among the insurances are going to pay for it, going to deny it, or going to underpay it.  

Yes, the built-in report generator can print a general report of all the services, but this very specific request cannot be made without manually altering the data obtained, and, of course, the data wouldn’t be able to explain the trend without the help of the administrative department. 

Credentialing 

Aside from reports, credentialing and payer contracting are still manual processes. Some software can determine whether the provider is in-network or not, but most of the time, the software only requires the provider information to be entered and the claims to be billed accordingly for the software to process the claims.  

A credentialing team is very important in order for the doctors/clinicians and the patient to be paid appropriately. A Neolytix case study illustrated a very good example. There was one clinician that was said to be credentialed to this insurance, so the claims were billed correctly. But then, when Neolytix got a couple of ERA’s, that didn’t make sense because the patient had been charged higher than before when claims were billed to a contracted provider.  

It turned out that the insurance wasn’t able to update their system; thus, the provider was still appearing as Out-of-Network, and they were processing the claims in Out-of-Network benefits. This is a good example of what software can’t spot on its own.  

Claims denials 

In regards to some claim denials, the software can account for the denial but won’t be able to alert the clinic about the pattern or trend in denials. Another case study from Neolytix provides an excellent example. 

Neolytix received a denial for a certain type of code, and the team was only getting the denial from specific insurance. It turns out that the said insurance has a limit to the number of units to be billed when it comes to this procedure code. So, in order to cut the back-and-forth exhausting part of doing an appeal, sending the documents, and waiting for the final status, a certain protocol has been established for that specific code and that specific insurance to ease the process. 

Communication 

Another field where MSO overshadows MPM software is the communication part of the billing process, especially billing questions from the patients. The software provides monthly billing statements and sometimes can be sent online. Regardless of having an online patient portal or e-mail capabilities, this will not explicitly tell them what is happening in the account.  

Instead of the clinic and the provider answering and explaining patient queries, the provider member services side of an MSO can do this task from them. 

Accounting 

The accounting department is another key element that separates the MSO from MPM software. The provider doesn’t have the spare time to oversee and audit financial statements. The software is useful for providing snapshots of the current stand of things, but it can’t pick up trends or hypothesize like humans can.  

MSO accounting departments typically assist the provider when it comes to their financial management. The information received usually includes personal insights that software can’t provide.  

Why choose Neolytix as MSO for your practice?

Neolytix’s HIPAA-compliant billing services have been helping small to medium medical providers for over a decade to improve their billing processes and maximize returns. We would like to illustrate some of the differentiating factors that set us apart from other MSOs 

At Neolytix, we are very keen on creating protocols specific to our clients’ needs. Each and every clinic is unique in its own right. That is why we created an internal standardized process but are still agile enough to adapt to a certain type of request per client or protocol per their specialization. Each department in Neolytix that are in collaboration with a specific client can understand the reports that were generated.  

Furthermore, nothing will be lost in the system. There is a point-person for a specific client that overviews the account’s status. All departments are interconnected, structured, and monitored optimally to minimize errors and improve overall efficiency. 

Another differentiating characteristic of Neolytix is that one of the key metrics whereby personnel is measured is continuous development. Online platforms are provided where staff enrolls in mandatory courses meant to upskill them and keep them updated regarding industry changes. 

Neolytix offers a-la-cart services that include everything from billing to marketing and finances. Our services can assist you all along the value chain- from the patient’s first encounter to verification, billing,  and more. Our focus is to help wherever we can to improve your internal processes so that practices not only benefit from one outsourced service but experience a synergy throughout their practice. 

For more information about medical billing for speech therapists, or other related services, schedule a no-obligation free consultation by completing the box below.  

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