How do I bill - in simpler to understand terms

This is an overall description of how the PropelEHR Billing Process works in terms of Billing Rules and Billing.

Billing Rules are set up in the Configuration Reference Libraries Billing RuleSets.

The Program is linked to the Billing RuleSet in the Program’s Program Operations tab, in the Operations Panel:

**This is our Overall Billing approach – **

For Residential… (the same approach works for other programs):

The Needed Setup:
For people in residential, you can bill for a billing day, xyz day, abc day, etc. Every program has different things you can bill for.

In the PropelEHR system, we set up what we call a Service. A Service are the things you do and can bill for. Our Service has a rate, and a quantity. The rate might be $200/day and the quantity for 1 billing day might be a quantity of 1. We might have another Service that is $180/day and a quantity of 1.

For every program, we define what we can potentially bill for. And, as the staff performs their daily activities, they are performing supports, people attend sessions (where they are clocked in and out, so we track the minutes they spent in the sessions), daily notes are being captured, bed checks are being done, etc. The staff is collecting a lot of data about the people in the program at all times.

A Staff Action Plan sets out expectations for each of the above things.

All of the above services get set up in our Service Inventory, for day hab, residential, vocational, day services, com hab, etc. for the things we might bill.

The Billing Schedule is where we say how much we are going to charge for the above services.

For the program…
The Staff comes along and is doing all of the work… they have a ‘To Do’ list of things they need to do, and the system is tracking all of their activities, and all their bed checks, etc.
All of the things they do roll up into the Staff Action – Data Log screen where we track everything that is happening and who is doing what… and all of that information is tracked in our Staff Action - Billing Opportunities screen.

In that screen, the system is telling us ‘here is a person at this program, they had bed checks, they had an IPOP, had staff actions, had notes, etc., and the staff thinks we can bill this as a billable day for that date, based on those activities’.

The DSP is responsible for selecting the type of billing they think can be done.

**Each agency must set up their own billing rules. **

These rules are based on the premise that in the past we billed for whatever the staff said, but we know sometimes we were told we can bill for something, but then when we sent it out for billing, it was rejected (for various reasons), or when we were told we can bill something, we found we could actually bill for something more, based on the situation, or even when the staff said we couldn’t bill for something, but we now know it could have been billed for. Now, PropelEHR will take care of that for you. PropelEHR has the system look and see if there are any discrepancies in the user’s logic being used to determine if something is billable or not, and then based on the rules we have in place, we will let the system make the decision on which services should be billable or not.

When we look at the Staff Action – Billing Opportunities page, we can select the services and run the billing rules on them… and the system will try to decide if the type of billing the DSP selected is a good match to what the system thinks should occur (based on the billing rules) or if there is another better way to bill.

When you do this for real In the Billing Rule suggestions page, even though the staff may have said we couldn’t bill for a particular provided service, the billing rules may say we could bill for a billing day.

Once the billing rules are in place, you can look at the Services that users said can be billed and you can run the rules to see if the system says it is billable or not. If the system agrees with the user’s suggested billing decision, then no changes are needed, but if the system disagrees, you get a whole list of services that need to be reviewed and reconciled, once a decision is made to either bill as recommended or bill as suggested by the system. In some agencies, the house DSPs will fix this in the system, and the Billing Coordinator will re-run the test to ensure the system is in complete agreement with all of the suggested billings, and then will continue with their billing.

In the billing opportunity screen, for example, the billers might plan to run the rules test process once a week and can do it by all or use the filters to run the rules test for each program. When you run the rules and the override column is blank – it means there is nothing wrong with the DSP decision… if there are issues, you can select them and click notify program director and send them an email to fix it. If I were doing it, I would keep doing it until the override column was blank…let’s say the program director was out of town…you have to decide to bill the way they said, or you can choose something else.

If I am the billing person, I might have to call the DPS and question why they felt they couldn’t bill for something. Once you decide what is billable or not… you are now ready to bill for them.

To Bill, we first create a statement (a new invoice) (it gets marked with an Icon in the Bill column, showing a statement was created). We go into the statement, see the list (of daily charges) and then send the document to our billing system for our billing submission.

The rule is just a 2nd set of eyes looking at what the staff has said. Like an expert looking at the data and second guessing what billing should be.

What we have been focusing on, is the rules….
Let’s said the rules said you needed to perform 9 bed checks for a services to be considered as a billable day, but because only 7 had been performed, the rules would say you can’t bill the service as a billable day – because of that, you might have to do a rehab day.

The billing person can also override the entries manually, at any time before submittal to the 3rd party billing software if they find some special circumstances.

The rules are setup in the rulesets in configuration reference libraries…

For each program, there are different rules -

There is an order of priority and for each program you can define different services and the rules for each service

Example:
• Days with one or more supports
• Has an IPOP created
• Has a Staff Action Plan
• Has one or more bed checks in the time window…

If all of the rules are met, the system will identify the service as a billable day…but if that is not valid, the system will look at the rules for the retainer day… and if that is not valid, it would look at Therapeutic days.

NOTE: We recommend you always add a Non-Billable Day Service to the bottom of the list (or else if it does not meet the criteria of any of the above, it would have another option to choose from… a Non-Billable day).

Other types of rule examples:
• Auditable support notes
• Session attendance
• Minutes of Group Support
• Other

Rules can be simple or involved.

If the Rule test says… ‘has an IPOP’, we can perform the test and it will tell you based on the rules that are set up…it will tell you if it meets the requirements for a billable day….and if not, if it meets any other day criteria.

It goes down the list and tries one rule then another until they find one that fits. We want to try to see if we meet the criteria for the one where we charge the highest rate… and then the 2nd highest, etc.

RuleSets – there are a whole slew of rules in the library.

In Residential, for example, cooking can overlap with reading a recipe, so we allow that overlap for residential. But other programs may not allow that. Some of the items ask for additional things… if I look at the # of supports with group size 1. The system will prompt you to entire the number of supports you need… for a full day, maybe you need 8 hours. For a half day maybe you need 4 hours.

The ‘Day with 15 minutes of more of support’ is actually only valid for monthly billing
‘Distinct weeks of support’ reflects how many weeks in the month you would do a support, to make it billable. It works by calendar month… so 3 would designate 3 weeks of that calendar month. When you see the word Distinct it means unique… if I do 6 supports in 1 week, the distinct weeks will count as 1.

That is what happens and how the system will calculate what is needed…

When you see the invoice (Finance>Invoice) it says here is the person, date of service, the service, the bill amount… the current list is informational and reflects what the current rate is as of today’s date. The Charge just shows us on the date of service, this is what the charge rate was…when we sent the file to the billing tool we send the Charge to them because that is what it was on the date of service.

When we see some pricing that appears to be off, it could be because the pricing was not set up correctly… we review the billable services and make sure they are all set up with the proper rates and effective dates. PropelEHR will add any missing actual billing rules in the system (for example, if the customer has to have a bed check between 12P and 1A…. PropelEHR will need to add that to the system).

Example, if I want to bill for Monday, we need a bed check on Monday night, but Monday night ends on Tuesday, so we realized when we check for bed checks, we need to look between 10P on Monday until 6A on Tuesday. That type of billing will take care of Residential, Day Hab, and ½ Day Hab, etc.. For billable days, we have a quantity of 1 and one rate.

The unit-based billing is slightly different….

For those, if I did 34 minutes of support and we are rounding up to the nearest 15 minutes, it rounds up to 45 minutes if you have 10 of those 15 minutes… in order to round up to the next unit. In those cases you would have 3 units of 15 minutes.

40 min of 1:1 time it would round to 45, and if you have 1:2 it would round to 45, but if you have 1:1 and 1:2, there would be 2 entries – they would not be added together.

Default Unit-Based Quantities:

Residential should be 1.
ComHab, default should be 0 (varies - if you entered a “0” it meant that the quantity would be calculated by the system.), we are still going to have pricing for those, based on group or support units pricing… per support units. Ex: Com Hab 1:1 should have 1:1 Support Units in Billing Schedule…

Let’s say 5 min of 1:1 and 5 min of 1:2, I can count as the 1:1 min if they are going to a 1:2 situation, and then bill at 1:2 rate. If you select the units for 1:2, it will roll up the 1:1 into the 1:2…the same with 1:3… it will roll up the 1:1 to 1:2.

The system will try to pick the one which provides the most revenue back to the agency, first.

If you didn’t want to add the 1:1 and 1:2 we will need to check the code.

When you do the billing opportunities for Com Hab, the system will calculate the dollar amount as the #units X price per unit.

Once you create the invoice, you can view it and then submit it to billing – it constructs the billing tool file with all it needs. You export it to excel, send the file to the billing tool and then click ‘Mark (the invoice) as Submitted’ – that will lock the document and the button to submit it will go away.

Needed Setup:

The locator code and revenue code need to be set up beofre you create the billing files – where you put in the qty, there is a box that says (service inventory) – Edit Service: Billing Modifier (Locator Code) and Billing code (Rate Code) – Cost Center (is the GL Account on your general ledger – this is optional to fill in) Billable and Active. Users must also have the appropriate account roles to perform the billing.

Looking at day hab program… in program options… you can subtract the minutes for lunch. When you see the billing opportunities you see session minutes and adjusted minutes… the adjusted minutes is after they subtract the lunch minutes.

The way the sessions work now on the program session calendar is the staff have attendance. People come in and out and the system logs all of the time, the clinic send them a spreadsheet saying 'Liza' was out 11:59 – 12:31… they have to subtract that, so there are no overlaps.

Shortly, we will have a side panel to show the ECW info (the system of record), the clinic would run the report in ECW and would upload the excel sheet into IMPOWR…the residential homes can then click on the Check In History, and then edit the entries. Our new change will provide a way to check for those discrepancies and highlight them… so you don’t have to look at all of them.

Before you do the actual billing in PropelEHR, we suggest you test it. If your billing company has a test system, you can test in there…but if not, you would have to call them in advance, because they would have to receive the billing file, flag it as a test in some way, and then cancel it from their system. With the test, you can check to see if it matches what is generated in your current EHR.