Article Published in AAPC Healthcare Business Monthly, 2018
Experienced nurses who have held traditional nursing roles make excellent candidates for coding, corporate, and managed care positions. We have a clinical understanding of medical procedures, and appreciate how coding and provider documentation complement one another. I have found this to be particularly true for myself, as I’ve embarked on a career in managed care.
What Is Managed Care?
Managed care is designed to manage cost and utilization of benefits, and to ensure the quality of healthcare plan members are receiving. Third party managed care organizations (MCOs) are typically contracted by insurance carriers. These organizations employ physicians, nurses, coders, and other non-clinical support staff to make determinations on the behalf of the insurance carrier regarding pre-authorizations, benefit management determinations (such as physical therapy needs, pain management utilization, etc.), and documentation accuracy of procedures reported within billed claims.
MCOs act a bit like an impartial third party, settling disagreement between friends, (i.e., provider’s office and insurance company). We hear both sides of the story, look at the facts presented, and make a decision based on evidence.
Coding is a vital piece of this intricate puzzle. For utilization management (pre-certification and benefits), diagnostic coding is particularly important. The diagnosis code drives the entire procedure: when the provider submits a diagnosis to request services for a patient, that code(s) tells the MCO why the requested procedure is necessary for the patient. Nurses with coding experience are a valuable asset to MCOs, for this reason.
New Payment Models Change the Equation
We have evolved to realize that paying providers to keep patients healthy (which should be the goal) is more valuable than paying for services billed. Fee for service increasingly is being replaced by value-based care and shared savings. As a result, correct medical coding is more important, than ever. Codes not only serve as a billing factor, but also translate to a score in a long list of quality measures to be met. Those scores now drive provider payments. This gives providers a stake in the game because, essentially, the provider is paid for saving the insurer money. This helps to keep costs low, and ensures preventative care is diligently preformed for patients.
Changes, such as rewarding providers for taking the best possible care of their patients—keeping them out of the hospital, ensuring they are taking their meds, and getting all those preventative services preformed—are revolutionizing how we approach healthcare, while keeping patients at its core. That’s what “managed care” is all about.
A Nurse’s Role in Managed Care
My role as a nurse in managed care is unique. Because I have coding and compliance training, I wear several hats. My main function is to act as a liaison between providers’ offices and our organization. I speak with certain provider groups regarding claims that have been “escalated” due to denials. Many of these are high cost claims that contain complex coding. In these circumstances, I will pull the cases apart with the Medical Director who made the initial determination on the claim. Together, we review the operative report and the CPT® codes submitted. My nursing background helps tremendously in these situations: a basic understanding of anatomy and physiology helps to piece this complex puzzle together.
In some instances, health plans will request written explanations of denials from the MCO to send to the provider’s office. In these cases, generally, the claims are reviewed carefully by the Medical Director and me. A written explanation is crafted, using CPT® definitions of the code and any citations from the operative report supporting our denial, as well as National Correct Coding Initiative (NCCI) references used in making the denial determination. These explanations are detailed and comprehensive. We hope that providing this level of explanation will help to educate the provider and/or billing staff as to how the determination was made, and what future coding expectations are for that type of procedure.
Advice for Nurses Looking for a Change
If I could offer any advice to nurses aspiring to join the coding world, I suggest first searching for opportunities within your current organization. For example, look to billing staff to explain procedure codes that have been submitted to health plans, volunteer to join your organizations compliance team, or look for areas of improvement within your providers’ documentation (CMS.gov has many resources available on documentation standards).
I would also recommend becoming a CPC®, and pursuing any other credentials that spark your interest. Compliance training often compliments a CPC® certification, nicely (I have found this to be true for myself). Becoming certified not only opens opportunities for you, but also tunes you in to all the intricacies of coding. I’m glad I took the opportunity to learn the coding and compliance aspects of healthcare, as they have a enriched my education and understanding of healthcare. Whatever your role or your goal, it’s a terrific thing always to be learning.
Bio: Lisa Tevolini, Nurse Specialist, has held various positions that have prepared her to excel as a corporate nurse. She started her career in a multispecialty practice as a nurse for a gastroenterologist. She later became IV and infusion certified and performed infusion therapies on patients who received biologics. Within the same practice she became the Nurse Case Manager for the practice and Assistant Clinical Manger, which allowed her to sit at roundtable meetings with the director of the practice and liaisons from the health insurance plans to discuss our metrics. In managed care, she combines her clinical skills with the skills she gained through interaction with health plans.
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