Private Pay: Level of Care Workflow for Kipu RCM

Let's review the process for treating patients without insurance (e.g., Private Pay) and billing the patient for Level of Care (per-diem) treatments with the Kipu EMR and Kipu RCM (Avea) Integration. 

Assign a Clinical Level of Care to bill a private pay patient for level of care (per-diem) services. When a clinical level of care is added to the patient and the payment method on their facesheet is set to Private Pay, the appropriate Level of Care codes will populate on the Billing Report for billable items. 

Important: Private Pay billing is only available for clients who have purchased the Patient Billing Add-on for the RCM. Please contact your Client Success Manager for additional information.

The process below can be used to bill Level of Care (per-diem) services for Private Pay patients.  For instructions on billing ancillary services for Private Pay patients, click here. 

System Configuration

Let's review how to set up the Kipu EMR for billing private pay patients using Clinical Level of Care.

Level of Care

Ensure that your organization has the desired levels of care configured. Click here for detailed instructions.

Services

You do not need to set up special private pay services. Our best practice recommendation is to bill for private pay using the same Level of Care codes and services configured for per-diem insurance billing and adding a Service Rate for the patient to indicate the Private Pay charge amount.

Payment Method 

Ensure you have at least one payment method set up with the Private Pay category. The Name of the payment method doesn't matter, it's the category of Private Pay that sends the Private Pay indicator to the RCM.

1. To confirm this, Super Admins can navigate to their Initials > Settings > Patients.
2. Scroll to the Payment Methods section and create or set at least one category to Private Pay. You can have any many Private Pay categories as needed.
   
   

Level of Care Private Pay Billing Workflow

Patient Setup

Let's review the key settings related to the Level of Care private pay workflow that need to be configured on the patient facesheet.

1. Create the patient record, ensuring all required fields are completed as this article outlines, including at least one diagnosis code.
2. Please ensure the Payment Method is set to a Private Pay payment method. This will automatically send over the Private Pay indicator to the RCM. If the payment method was selected before the category was updated in settings, please deselect and reselect to ensure the system sends over the indicator.
1. Note: If the patient was sent from the CRM with the Private Pay option selected, the payment method in the EMR should default to Private Pay. 
3. Click Manage Insurance. This allows us to quickly adjust the patient's insurance profile within the RCM.
4. Click the Set to Private Pay button.
   
5. Select the Effective Date and click Create.
   
1. If the patient has an existing insurance, this will automatically add a termination date to the patient's previous insurance set to the day before the Private Pay effective date. 
6. The patient will display as Private Pay on the Attendance Calendar.

Add Service Rate

You must add a Private Pay Service Rate for this patient. This ensures the system appropriately matches the EMR charge to the correct RCM service and allows you to create a specific rate for the patient.

1. Click on the Manage Insurance button on the patient facesheet in the EMR or navigate to the Scheduling and Utilization tab of the patient's treatment episode in the RCM.
2. Click on the Service Rates tab. 
3. Click Add Service Rate.
4. Fill out the Add Service Rate form:
   

   Select Private Pay from the Service Rate Type drop-down. Set the Start and End Dates for this rate. It's important that this date range includes all dates that you will be billing for this service to prevent any batch transmission errors for "No Utilization Plan.." Choose the treatment Facility. Select the Service (in this case the level of care). Choose the Rendering Provider and Billing Provider.  Set the Unit Rate.

5. Click Add to save.  

Add Clinical Level of Care

From the patient chart, locate the Evaluation that allows Clinical LOC assignment. Please note: This can be any Evaluation form with the patient.level_of_care_clinical field. 

1. To start, click on the Add Document icon.
2. Search for the document and click the Edit icon to add and open. Remember, you must have the same function as the form in order to add and edit.

3. Enter the Date of Change to indicate when the patient transitioned to the new level of care. This will impact which dates can be billed for this level of care in the RCM. Then, use the Transition to level of care drop-down to select the desired Clinical Level of Care. Complete the document as needed, then Sign and Submit.

   
4. The Clinical LOC displays in the header of the patient chart. 
   

Add Billables 

Next, add billable Group Sessions or Evaluations to the patient. Evaluations and Group Sessions that are added during the same date range as the patient's assigned Level of Care will automatically bill using the LOC billing code and duration requirements. Remember, any items marked as billable and ancillary will bill using the code selected for the billable item and are billed separately from the LOC (per-diem) items.  Click here to learn more about billable items. 

Billing Report

For all per-diem items (billable, not marked ancillary), the clinical level of care will pull into the billing report with the codes associated with the patient's Level of Care. Select and Transmit to send to the RCM.

Attendance Calendar (RCM)

The Patient's billables appear on the Attendance Calendar in the RCM. Click Submit Treatments for Billing to send the charges to the Work Center.

Patient Billing (RCM)

Follow the steps in the Create Patient Billables section of the Generate Patient Billables for Private Pay article in the RCM Help Center to complete the process.