Ep. 11: Payment Integrity [TRANSCRIPT]

Abby Rose Esposito, Sr Marketing Strategist (00:09):

Hello and welcome back to the MediSked Podcast. My name is Abby Rose Esposito, and I am a senior marketing strategist at MediSked. I am pleased to welcome Lauren Tantalo to the podcast today. Lauren is the Vice President of Professional Services and she has been at MediSked for 10 years. She’s on the podcast today to discuss payment integrity. So let’s get started by defining payment integrity. For our listeners who might not use that term regularly, could you explain what we mean by that language?

Lauren Tantalo, Vice President (00:37):

Sure. And good morning, Abby Rose. It’s nice to be on the podcast. Payment integrity is generally the reduction of fraud, waste, and abuse in billing practices. Fraud, waste and abuse are similar and sometimes kind of overlapping categories with differences mostly with intent. So fraud is intentional criminal actions that can result in inappropriate billing. Waste is unintentional actions that also result in unnecessary costs or inappropriate billing to the payer.

Lauren Tantalo, Vice President (01:09):

Abuse is also intentional, but it’s kind of a broader category that includes negligent as well as inappropriate billing practices. So MediSked products have guardrails built in to prevent all of these.

Abby Rose Esposito, Sr Marketing Strategist (01:19):

So what are some of the ways that MediSked products help with payment integrity?

Lauren Tantalo, Vice President (01:23):

Payment integrity really starts long before an actual claim is submitted. Payment integrity starts at the point where we’re identifying that an individual is eligible for services or supports within the MediSked platforms. We can only schedule, create documentation and subsequently bill for services that an individual is authorized to receive. So within MediSked platforms, both connect and coordinate. We can do manual authorizations where a user actually goes in and links up the services that an individual is authorized to receive with that individual’s record. Therefore, enabling scheduling and documentation. We can also do automated authorization via integration. So if we’re processing an enrollment file from a payer or from a state Medicaid, we can make those service linkages automatically.

Lauren Tantalo, Vice President (02:14):

And the linkage is what allows a user who’s creating a schedule to actually indicate that that individual is receiving the service. The med platforms also prevent users from scheduling an individual for two services simultaneously. So it’s important in many instances, you’re not allowed to bill for two services that occur at the same time and, and the system has controls in place to prevent that.

Abby Rose Esposito, Sr Marketing Strategist (02:40):

Got it. Makes sense. How about ensuring that services are actually performed or delivered appropriately?

Lauren Tantalo, Vice President (02:48):

Yeah, so like many software platformsMediSked products tag actions that you take in the platform with the name of the person who took that action as well as as the date and timestamp. Examples of this can include scheduling services or tasks, filling out service or contact notes or making updates to a person’s profile. So there’s no way for any system really to prevent a person from scheduling or documenting services inappropriately, but we do provide some accountability here so that you can tell who has done what and there’s no way to inappropriately schedule somebody for something and kind of get away with it without, you know, having your name attached to that action.

Lauren Tantalo, Vice President (03:32):

We also do check in and check out for certain services. This is something that can be enabled and we do have strict controls that can be enabled for geographic location alerts. You can indicate where a service is supposed to take place via latitude and longitude coordinates, and we can set alerts that get sent to supervisors if an employee checks in more than a certain distance away from the target latitude and longitude. So we wouldn’t want to have somebody inappropriately checking into a service from their house before they’ve even driven to the location where the service is supposed to be taking place. Similarly, we can have telephony restrictions where if somebody is supposed to call in to start their shift or start the service, they have to do that from a dedicated phone number. So it’s usually the individual’s phone number who’s receiving the services and calling in from any other phone number would fail to check the person into the block.

Lauren Tantalo, Vice President (04:29):

Some of you might be listening to that and be thinking, oh, that sounds like electronic visit verification. EVV is a whole federal program dedicated to reducing fraud, waste and abuse via collecting those check-ins and checkouts and including it with the submission of billing claims. We won’t get into that whole topic here, that’s a whole other podcast that we could probably do sometime. But in short, MediSked does support EVV requirements and works with payers and aggregators in a number of states. Finally, when we’re talking about ensuring that services are actually performed or delivered appropriately, both the connect and coordinate platforms have an audit feature that you can configure to require a second set of eyes on logged service notes, encounters, or even plans before they’re published. And in those instances, of course the approver’s name is logged to so you can see who reviewed the item, the service note or the plan and gave it a thumbs up before it’s finally published.

Abby Rose Esposito, Sr Marketing Strategist (05:30):

Cool. Tell us about generating the actual billable claims to be submitted.

Lauren Tantalo, Vice President (05:36):

Sure. So we’ve talked a lot about scheduling and delivering services appropriately, and that’s because MediSked platforms generate our billable claims based on the service or outreach data that’s been documented. So that’s kind of unlike a more traditional billing platform where a user would just key in the codes and amounts and generate a billing file to be submitted. So MediSked platforms calculate appropriate billing amounts based on the services that have been logged. And the rules around that can be fairly complex and that’s one of the primary advantages of MediSked platforms is that we can very quickly and accurately calculate what we should be billing based on the documentation of services that have been provided. So the appropriate level of service to Bill obviously can vary significantly based on program, based on the state based on the regulatory body.

Lauren Tantalo, Vice President (06:30):

But common items here are the duration of service performed, the number of tasks or items worked on whether cumulative encounters or services provided over the course of a given month meet the requirements for billing and also whether annual requirements have been met. So in some instances, for example, you can only bill if you’ve had a certain number of meetings talking about a life plan over the past six months or something like that. And we can calculate those things into monthly billing as well. We also can do billing suspensions. So in instances where individuals may have lapsed eligibility or they’re otherwise unavailable to receive services based on things like hospitalization or incarceration we can create a billing suspension that will physically prevent the submission of billing claims for that individual for the duration specified. And those claims can be billed after an exception is lifted.

Lauren Tantalo, Vice President (07:32):

So if you have logged services but you’re unable to bill for the month because the person is hospitalized, if they’re released from the hospital and you remove the billing suspension, if the service is eligible to be billed, it can still be billed with those logged documented notes. Other features in our platforms include the historical bill rates, so if there’s a rate change, you don’t have to do the rate change all at once. You can enter a date range where the billing rate was a certain amount, and then another date range where the bill rate is a different amount. So if you have a time period where your billing claims from both before and after the rate change, the platforms will pick that up automatically and generate the correct billing rate without having to do any kind of manual intervention. And finally, when it comes to payment integrity with billing claims, we have configurable timely filing deadlines.

Lauren Tantalo, Vice President (08:25):

So whether your timely filing deadline is 90 days or 180 days or a different number the platform won’t allow you to submit claims after the deadline without a valid reason code attached. It’ll give you a little error message and you have to pick a reason code in order to submit claims after the timely filing deadline has expired.

Abby Rose Esposito, Sr Marketing Strategist (08:45):

Nice. I should have asked you this earlier, but does all of this apply to both our MediSked Connect platform, which is our provider agency’s specific platform as well as Coordinate, which is our care management platform?

Lauren Tantalo, Vice President (09:01):

Yeah. The feature set is very similar between the two platforms. There are some, you know, specific, for example, specific billing requirements that we really only have in like the Connect platform because those are the types of things that are relevant to the services that provider agencies deliver.

Lauren Tantalo, Vice President (09:18):

So for example, we talked a little bit about how you can calculate appropriate billing levels based on the number of plan activities that have been worked on. That’s a scenario that would really only be applicable in the Connect platform. In coordinate we’re talking more about the number of outreaches or encounters that have occurred during the course of a month and whether those outreaches are in person or via phone call or email. So generally yes, the, the features are basically the same with some variation based on the appropriateness of the use cases.

Abby Rose Esposito, Sr Marketing Strategist (09:50):

Got it. Makes sense. Well, is there anything else we should know about payment integrity?

Lauren Tantalo, Vice President (09:55):

Oh, there’s probably so much more we should know about payment integrity, but I would just say that this isn’t all encompassing of all of MediSked’s capabilities around payment integrity. There are other very specific scenarios that we can handle and guardrails that we can implement to help ensure payment integrity for our clients. So if there are specific scenarios, use cases that you think MediSked might be able to help with, please feel free to reach out to our support team to be routed to the appropriate person who can, who can help you handle those scenarios.

Abby Rose Esposito, Sr Marketing Strategist (10:25):

Awesome. Thank you so much for being here. We loved having you on the podcast and we hope to have you back soon.

Lauren Tantalo, Vice President (10:32):

Great. Thank you so much for having me.