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The Challenge

A large telehealth company was concerned about clawbacks for billing non-compliance

The Outcome

95% of claims with improper documentation were identified before being sent for payment.

Improper Payments & Clawbacks Affect the Bottom Line

Based on a sample of claims from 2019-2021, the Centers for Medicaid and Medicare Services found that improper payments to providers totaled more than $98 billion. Improper payments for behavioral health services delivered fee-for-service were estimated at more than $3 billion dollars. These estimates do not account for improper payments found by states, Medicaid managed care insurers, and commercial insurers. Improper payments occur when payments are made for claims with missing documentation, documentation errors, undercoding, and upcoding.

Improperly billed claims can be a huge problem for behavioral health organizations. When improper payments are found, payers can request providers return the amount that was improperly reimbursed, commonly known as a clawback. Clawbacks can result in a loss of profitability and cause financial trouble. Additionally, many behavioral health providers fear being named in publicity about clawback amounts, which can cause reputation damage.

Some of the most common problems with claims submission in behavioral health include:

  1. Recording of time spent with the client: Progress notes must document the actual time spent with the client. Appointment logs or schedules are not accepted forms of documentation.
  2. Proper documentation of multiple services: If more than one service is provided on the same day, the documentation must reflect how much time was spent on each service.
  3. Allowing unlicensed professionals to bill: Providers must be extremely careful and follow the proper guidelines in their state for billing “incident to” for unlicensed professionals or professionals still in training.
  4. Cloned notes: Cloned notes occur when providers copy a note or write a generic note and copy it over and over again for different clients or the same clients. These notes are often rejected because they are not personalized and individual-specific enough.
  5. Improper coding: CPT codes are not appropriate for the service rendered or do not match the documentation.

A large national behavioral telehealth company based on the East Coast that provides psychotherapy to the commercial population was concerned about errors in their billing. Executives knew that clawbacks could have a big effect on profitability. Additionally, there is a commitment by payers to crack down on fraud and abuse in telehealth. The Office of Inspector General in a September 2021 letter announced more than $1.1 billion in fraudulent charges related to telehealth.

Implementing Eleos Health’s Compliance Automation to Improve Billing Compliance

The leadership at the large telehealth company knew that their manual review of all progress notes was not feasible in the long term. They wanted to be able to identify as many instances of non-compliance as possible. The company explored technology solutions that could potentially help improve compliance and choose Eleos Health’s Compliance Automation solution.

Eleos Health offers multiple features to improve billing and compliance. Using artificial intelligence (AI) and Natural Language Understanding (NLU), Eleos Health analyzed the progress note requirements of each of the telehealth company’s payers. Using its proprietary engine Eleos Health provided a ‘safety net’ for compliance and billing teams:

  1. Ran on top of the session, generates an individual-specific note, and ensure that the correct CPT code is recorded for the services rendered.
  2. Ensured that the duration of the session matches the duration recorded in the note
  3. In the case the note was manually written by the provider, Eleos checks that the note is individualized and person-centered rather than generic or a copy of a previous note
  4. Used text-based natural language to make suggestions on how to improve the note (similar to spell check in Microsoft Word or Grammarly).

In addition to assisting clinicians in fixing the note at the source, Eleos Health allows compliance teams to identify problematic notes faster without having to wade through compliant notes.

The Outcome:
Eleos Health Identified 95% of Notes with Improper Documentation

In an analysis of over 5,000 notes at the national telehealth company, Eleos Health was able to identify 95% of improper documentation. The Eleos Health analysis found that 38% of notes had improper documentation. The most common errors found in improper documentation included overcoding (65%), missing documentation (25%), and undercoding (10%). In total, the use of Eleos Health Compliance Automation solution identified $70,000 in potential clawbacks.

Staff members noted that the platform made their jobs easier. Compliance staff were able to triage notes with improper documentation rather than reading through both correct and incorrect notes. Clinicians also liked the assistance in correcting their notes and making sure they were done correctly the first time. Spending time correcting notes only adds to their administrative burden.

What is Next?

Health care and behavioral health are increasingly identifying inefficiencies in managing not only billing but the entire revenue cycle. Many tasks related to revenue cycle management are repetitive, manual, and do not significantly increase revenue. By automating the revenue cycle using artificial intelligence, staff can focus on complex, high-value tasks that improve the revenue cycle. In the future, automating the revenue cycle will not be an option but a necessity to remain profitable.

Eleos Health intends to assist behavioral health organizations with automating the revenue cycle with their industry-specific knowledge. Eleos Health plans to expand the use of its billing and compliance platform making revenue cycle automation commonplace for behavioral health.

About Eleos Health

Eleos Health has pioneered the new category of ambient Voice AI workflow solutions to drive operational and clinical efficiency for behavioral health providers. Eleos’ advanced AI-based Care Intelligence solution runs securely in the background of therapy sessions to digitize auto-generated notes, analyze hundreds of data parameters within each session and provide real-time insights related to the delivery of evidence-based care. Clinicians can use this data to improve care for clients while reducing their documentation burden. Eleos Health leverages this shared knowledge of community therapists, clinicians, academics, hospitals, and researchers to deeply understand what is working for every person and power the future of personalized behavioral health.