AHLA's Speaking of Health Law
The American Health Law Association (AHLA) is the largest nonprofit, nonpartisan educational organization devoted to legal issues in the health care field. AHLA's Speaking of Health Law podcasts offer thoughtful analysis and insightful commentary on the legal and policy issues affecting the American health care system.
AHLA's Speaking of Health Law
Health Care Claim Lifecycle and Medical Coding: Why Are They Important to Health Law Professionals?
Kathy Roe, Managing Attorney, Health Law Consultancy, speaks with Christine Burke Worthen, Member, Epstein Becker & Green PC, about two important yet not always well understood areas of the health care ecosystem, the health care claim lifecycle and medical coding. They discuss why it is important for health law professionals to have a basic understanding of these topics, the role that artificial intelligence is playing, and AHLA’s recently released Health Care Claim Life Cycle 101 & Medical Coding 101 courses, of which Christine contributed. From AHLA’s Payers, Plans, and Managed Care Practice Group.
Watch this episode: https://www.youtube.com/watch?v=qigQfdPfEvs
Learn more about AHLA’s Health Care Claim Life Cycle 101 & Medical Coding 101 courses: https://www.americanhealthlaw.org/education-events/101-online-courses/the-health-care-claim-life-cycle-101-medical-codin
Learn more about AHLA’s Payers, Plans, and Managed Care Practice Group: https://www.americanhealthlaw.org/practice-groups/practice-groups/payers-plans-and-managed-care
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SPEAKER_02:Hello, everybody, and welcome back to AHLA's Speaking of Health Law Podcast. I'm Kathy Rowe. I am a managing attorney with Health Law Consultancy in Chicago. It's a boutique health law firm that focuses on regulatory counseling and contracting. I'm here today on December 22nd with Christine Worthen. I am the chair of the Payers Plans and Managed Care Practice Group. And Christine is one of our vice chairs. She is going to be chatting with me today about her contribution to an AHLA 101 program. And so, Christine, why don't we start off by introducing yourself and telling folks about what you've done with AHLA?
SPEAKER_01:Great. Thanks, Kathy. So, yes, Christine Worthen. I am a healthcare regulatory and ERISA attorney with Epstein Becker Green. I am based in their Washington, D.C. office. I've been practicing in the healthcare regulatory ERISA space for 25 years. I've been both in-house with a large health system, and I've also been private practice. I became involved with the AHLA probably close to 15 years ago. I started by shadowing the hospital and health systems practice group. Then I was fortunate to become a vice chair of the payment and delivery reform practice group. And then I was the chair. I then went on to be a vice chair in the regulation, accreditation, and payment practice group. And at present, I'm completing my last term as vice chair, as Kathy mentioned, of the Payers Plans and Managed Care Practice Group. Over the years, I've been fortunate enough to cultivate relationships with a bunch of incredibly talented practitioners, and I've been able to contribute to numerous live presentations, webinars, articles, podcasts, and books. I'm glad to be here.
SPEAKER_02:Thanks, Christine. So why don't you tell me and our audience a bit about the 101 programs that AHLA offers and in particular the 101 claims and coding series to which you contribute? What is it and how'd you get involved?
SPEAKER_01:So this was an invitation to give a basic, as the name implies, 101 basic intro to claims and coding process. And my piece is focused on the claims process. Two colleagues of mine at Epstein Becker Green, Rob Wanderman and Will Walters, took the laboring or on the coding piece. And it's meant to be not just an informational overview by way of a slideshow kind of approach with the relevant information, but it's also meant to give bite-sized synopses from the presenters in terms of practical tips and guidance that you might find along the way. I think that it does a nice job of getting the information across in bite-sized manageable chunks without going too deep in the weeds. But it would allow a practitioner who's not necessarily familiar with the space to get some basic terminology down, some basic things that would be relevant to their practice and help to, you know, maybe pique some more interest or at least be conversant in the area as they do their day-to-day jobs.
SPEAKER_02:Christine, one of the questions that I do have and want to get your answer to is why is it important for AHLA members right now to be learning and understanding the healthcare claim lifecycle?
SPEAKER_01:I think that in this environment where we're facing uh reimbursement headwinds, changes in Medicare Advantage, uh payer policy, I think that the notion of submitting complete and accurate claims becomes more and more important for several reasons. One is Medicare Advantage payers get paid based on uh coding and what is documented on the claims. And what might not be evident is a lot of times in order to submit a claim, you don't necessarily have to put every single diagnosis, for example, on a claim. And that becomes more important as we think about value-based care and we think about gap closure, and we think about all of the other things as you are looking at outcomes. And did we do this? And are we keeping patients healthy, for example? Um, and so understanding how the claims life cycle, and you know, not necessarily knowing where all of these things go on a claim, but being able to understand that a clean claim becomes much more, or at least from the payer's perspective, becomes much more than just doing the basics. It becomes an exercise in uh improving relationships because now you're getting all of that uh rich data that can be captured in the claim, getting that to the payer, the provider in turn, when they're in a value-based agreement, can get some other payer claims intel that they might not necessarily have because a patient of theirs sought care at another venue, and so they might have some gaps there. Um, so really um making sure that folks understand that the claim submission process isn't just a box check to get paid, it really is about creating a really um robust data set to make sure that you've got a complete uh patient profile from a claims perspective, at least.
SPEAKER_02:Okay. And so this course is part of a series on claims and coding. Can you speak to why coding is important for health lawyers to understand alongside of the healthcare claims lifecycle?
SPEAKER_01:Yeah. So complete and accurate coding is another um uh that's that's very important from a not not just from a payment, but from a regulatory perspective. And um changes in coding, for example, you know, there's been some recent changes in EM coding, um, making sure that you're staying up to date with, or at least being aware if you don't necessarily need to know how to encode an encounter, but being able to understand and articulate, okay, so EM coding's changed, and now we need to understand what that entails. And then on the flip side, payers come out with policies from time to time. Sometimes they involve down coding, that that seems to be another hot topic these days, and then just understanding how the coding process from the medical record and documentation then feeds into how reimbursement occurs and whether and to what extent you're in a payer audit that's looking at coding practices and whether you are doing the due diligence on the provider side to make sure that coding and education is there. Um, also HCC coding is has been and continues to be a big focus. And so understanding the basics that go into that to be able to, you know, issue spot, but also to be conversant and and to help uh navigate your client through through those choppy waters.
SPEAKER_02:So listening to it, it sounds like somebody doesn't need to become a medical coding expert, like folks have talked in recent years about tech lawyers and becoming an IT coder. It sounds like a baseline understanding is sufficient in order for one as a health lawyer to support his or her client, whether it's a payer or a provider or other marketplace participant.
SPEAKER_01:Yeah, I I think that's right. I think with regard to the role that uh we we play as attorneys in in helping the clients navigate you know regulatory strategic um objectives, there are always going to be those boots on the ground folks who have that deep expertise in the in the coding space. And certainly, you know, as I work with health systems and we're we're working on issues, um, building relationships with the with the revenue cycle team and those types of individuals really goes a long way because uh um their deep expertise in the coding arena, coupled with your ability as an attorney to flag some of the issues that are cropping up, and then that can translate into you know these really great robust discussions as to whether or not the the um some of the you know audits that they're doing internally might need to improve. Um, maybe there's an opportunity to uh think differently about payer policy intake and making sure that you're really understanding what the payers are saying in their policies. I know I've seen that come up before where folks think that they're doing everything, quote, correctly, but it's just some of these nuances in the wording that provide an opportunity to say, hey, we may need to update you know this billing logic, or you know, in worst case, do we have an overpayment? And also in the reverse, identifying underpayments and payments to which you're entitled.
SPEAKER_02:Listening to you, it prompts me to raise a question uh that's in almost every conversation, and that is where does AI fit in in all of this?
SPEAKER_01:So I think that AI, at least in my experience, has come in in a couple of places. Um one is ambient listening and and what that means in terms of pulling that type of information in for purposes of medical record documentation and capturing, you know, aside from all the patient consent issues, but being able to feel confident that what is being transcribed is complete and accurate, and then to the extent that it forms the medical record to which a practitioner is signing off on becomes important. The other one that I've run into and seen and advise on is coding suggestions. So, based on what is being presented in the medical record, a suggestion for a code may come up. And so you always want to be mindful of you know, these codes are being suggested. Um, you always want to make sure that the right code's being suggested, that the physicians always, the practitioner, billing practitioners always making sure and doing a double check on, yep, that code's been suggested and yes, suggested in that, and yes, that that is the the right code. Um, so I think AI will continue, um especially with the you know the recent executive order and the the federal versus state law, I think it'll continue to be an area of evolution, but I also think that there's um room for improvement because the the uh revenue cycle process can be so cumbersome and and and and involved that um to the extent you can lighten the load, so to speak, but also do it in a compliant fashion, I I think is is a win for everyone.
SPEAKER_02:Let's dig in, talk about the subject of what you did for your 101 course. It was on the healthcare claim life cycle. Do you want to talk a bit about that and how you tackled that topic?
SPEAKER_01:Sure. So the um the the intent or you know, the the backdrop for the course is that it's not just about what you have to do from a business process perspective related to um healthcare claims, but also helps to um organize and present the different laws that regulate healthcare claims depending upon the line of business. Um, for example, um, we get into a bit about CMS, we get into a bit about the commercial payer claims processes, some of the nuances with the different laws, since we've got, you know, No Surprises Act has come into the mix. And so it's it allows you to distill into different categories just based upon which uh lens you're looking through. Um and it it allows you to kind of have a both a fulsome look at all of the different um types of lines of businesses as well as trying to give folks a little bit of uh distinction among the different ones so that you can better understand how they all fit together. Depending upon whether you're in the managed care space, um either on the payer or provider side, or you're advising uh providers and suppliers on their lines of business, whether it's fraud, waste, and abuse or basic nuts and bolts and regulatory requirements. It's pretty important to just understand the basics. You don't have to have all of the knowledge details on everything that goes into extraction from the medical record to the claim submission process and so on, but it does allow you to understand and you need to understand the basics for the claim submission and how each step in the process is so important from a regulatory perspective and making sure that claims are submitted, that they're complete and accurate claims, and what things may come into play when you're in the process of submitting the claims, things that you know payers look at where they think that or they're saying that the claim is not complete, or if you're going through the prior authorization or the utilization management process. And then what happens when you're in the appeals process and in the event you have to proceed to dispute resolution, it really helps to understand all of the basic components, including, for example, timely filing. Are you following the appeals process, um, making sure you know certain payers may have different processes for appeals, which are extremely important to follow, especially if you're trying to dispute claims, um, and and understanding look back periods and the like, um, and making sure that you're you're you understand what a complete claim looks like and the and things that may um impact whether or not a claim was submitted properly.
SPEAKER_02:I started out my career working for health insurance, hurricane back all of those years ago. I'm like, I don't think I've ever had any sort of training. Like, here's where it starts and here here's where it's it ends. I just sort of picked it up along the way. But as I was watching the course, it struck me that it wouldn't be relevant only for somebody who, like in my situation, worked for an HMO or a health insurance company. It really seemed to have a broader reach.
SPEAKER_01:No matter where you are in the healthcare regulatory space, I mean, providers uh need to submit claims to get paid. Um, and so for example, especially in, you know, we've got Medicare Advantage and we're facing headwinds as we go into 2026. You're going to have payers that are, you know, continue to implement policies that providers would say uh erode the payment, payers might say or want to ensure complete and accurate payment. And so really understand what understanding what goes into that claim will allow you to better advise your client and to really get into okay, for example, a payer policy is coming out, whether or not people are taking uh issue with two midnight roles and seems to be a hot trend right now that the payers are focusing on. And when you're looking at understanding claim submission, um impacts of medical records, um, especially coverage and payment issues and all those nuances, understanding the basics of the claim submission process, um, I feel is is quite helpful as you try to navigate those choppy waters for your client.
SPEAKER_02:All right. I think that's uh wrap for today. And I want to thank you, Christine, for coming on and sharing with the audience a little bit about the 101 course that you put together. And if folks didn't catch the name of that course, it's the Healthcare Claims Light Cycle, and it's part of a series called the Claims and Coding Series. So there's a companion course on coding. And otherwise, we just wanted to give you a glimpse of some of who we are in the payers, plans, and managed care practice group and the sorts of things that we're interested in.
SPEAKER_00:If you enjoyed this episode, be sure to subscribe to AHLA Speaking of Health Law wherever you get your podcasts. For more information about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org and stay updated on breaking healthcare industry news from the major media outlets with AHLA's Health Law Daily Podcast, exclusively for AHLA comprehensive members. To subscribe and add this private podcast feed to your podcast app, go to americanhealthlaw.org slash daily podcast.