Insurance companies are merging, healthcare plans are continuously changing, and patients are routinely changing plans trying to find affordable coverage. All this coupled with growth in prior authorizations, leads to one of the more challenging environments ever for providers to try to increase collections from insurance companies. One management methodology to help radiation oncology providers succeed is the Six Sigma concept of eliminating non value-added time.To be a value-added activity an action must meet all three of the following criteria:
- The customer is willing to pay for this activity.
- It must be done right the first time.
- The action must somehow change the product or service in some manner.
When applying the definition of Value Added Time from Six Sigma to payer follow up one can quickly conclude that none of payer follow up activity is value added. So, the key is to avoid payer follow up in the first place. The Six Sigma methodology relies on a collaborative team effort to improve performance by systematically removing waste. For example, when our team evaluated reasons for needing payer follow up we identified opportunities for improvement based on different insurance carriers requiring different coding methodologies.
- One example is submitting the “from” / “through” dates on the physician treatment management codes such as (77427, 77431, 77432, and 77435). Coders review documented management of a five-fraction period and the requisite face-to-face encounter between the physician and patient occurring within the date span. All insurance carriers will require the same codes, but carriers differ on the requirements of the dates associated with the codes. CMS doesn’t give specific guidance on from/through dates. However, some Medicare Part B contractors do require a “from” date, the first date associated with the treatment management code, and a “through” date, the last date within the five-day span. Omitting the from and through dates on claims submitted to carriers that require them will trigger a denial. Conversely, providing the dates for carriers that do not require the from and through dates may also trigger a denial.
- Another example is related to G-codes. In 2015 new codes were introduced for reporting IGRT. CMS requires physicians and freestanding facilities to report G-codes and/or 77014 depending on the type of IGRT being used, while hospitals should report 77387 for all forms of IGRT when it is appropriate to bill IGRT. However, many providers and payers will continue to encounter difficulty distinguishing between when to report CPT® codes and when to report G-codes for IGRT services. Additionally, many payers have implemented different reporting requirements for the same image guidance services. Some commercial carriers and some Medicaid plans don’t use the G-codes so the coders must determine whether or not to apply G-Codes or 77-codes based on knowledge of the carrier's preference.
These are only two of many examples where following a Six Sigma methodology that tracks value added time and links it to output data, process data, and input data can be beneficial in improving your process. To help improve our radiation oncology coding process New Bedford determined that coders need to be supported by a workflow rules engine that will identify and flag any potential denials based on payer preferences. It is typically 10x faster and cheaper to identify and fix a potential denial than to have to correct a denial through payer follow up.