As the U.S. entered life amid a pandemic there was a great concern amongst healthcare leaders as to how we could appropriately and effectively see and treat patients without increasing risk of exposure to the prevalent COVID-19 virus. Fortunately for U.S. healthcare consumers, telehealth had been a growing practice prior to the onset of the pandemic. If a healthcare provider had not been engaged in telehealth practices prior to the pandemic, it had at least been on the radar. This familiarity of the telehealth concept in addition to the increased flexibility in regulation and improved reimbursement models created a pathway to execute virtual care during the pandemic at a previously unimaginable scale.
Just as providers had to exercise agility in treating patients through new care modalities, so did those team members behind the scenes who ensure patient care visits are documented, coded, and reimbursed accurately. At the start of the pandemic diagnosis code sets for COVID-19 infections had not been created and how to appropriately document and code a telehealth visit was unclear. This lack of clarity and the newness of the situation created an increase in claims denials from health plans for provider groups to navigate.
To achieve operational efficiency, it is paramount to learn from these denials and create processes to not only successfully appeal a denial but to ultimately augment practices to prevent the denials. To do this, you need deep subject matter expertise to guide your team.
This is exactly the situation one of our client partners, a large retail clinic provider with 200+ clinic sites, found themselves in throughout 2020.
Shearwater Health strives to expand the size and impact of clinical teams, not just through staff augmentation but through partnership and utilization of an internal team of industry leaders and subject matter experts.
During the rapidly changing landscape in 2020, Shearwater Health and the premier retail clinic provider developed a communication process and feedback loop to ensure quick learning and practice changes. The teams would meet frequently to discuss denials, report reasons for denials, review updated guidelines and publication, and implement education plans for both providers and coders to minimize future denials
This type of transparent partnership ensured the success of both teams. The retail clinic provider sharing their denials and internal practices allowed for the Shearwater Health to apply subject matter expertise and industry insights to determine root cause and provide guidance for process improvement. The result of the strong partnership was and continues to be high quality documentation, strong coding accuracy, and maximized reimbursement.
