The medical billing process is the engine room of your medical practice’s entire revenue stream, whether you’re a large multi-specialty group or a small provider community clinic. The name of the game with any engine, and with your billing, is efficiency: getting the maximum return for your efforts.
Improving your medical billing process, and increasing your engine’s efficiency can be achieved in a number of different ways, whether by your in-house billing team or an outside medical billing specialist firm. The trick is to focus on specific processes within your medical billing protocol that can be improved to dramatically revitalize your revenue cycle stream. All of these processes aim to reduce insurance claim denial rates, reverse false denials, and prevent them from happening in the first place. We will discuss five specific ways to improve your medical billing practice.
Get Ahead of Your Patient Intake
The billing process begins the moment a patient approaches the front desk to check in. It might surprise you that the number one reason for insurance claim denials is the inaccurate recording of patient demographic and insurance information. Insurance claim denials stemming from patient intake errors can be particularly damaging to your bottom line because the amount of time it takes to process a claim appeal is usually longer than the deadline set by the payer, meaning the denied claim must simply be written-off by the medical practice. Instead of being a constant source of revenue loss, this could actually be a chance to jumpstart your point-of-service protocols and initiate a different system of collecting information to prevent errors. Some changes could include streamlining paperwork and forms to remove unnecessary portions, or offering emails or online forms through your website that will allow patients to pre-register their information before physically arriving at their appointment, thus allowing the front desk time to verify the information by the time the patient walks up to the check-in desk.
Solidify Authorization Requirements
You know the drill with pre- or prior authorizations: for any procedures that go beyond routine care (think large-body MRIs, upper endoscopies, polysomnography studies, etc.), authorization that the procedure will be covered by an insurance company must be obtained before the procedure is ordered, or there is a very high risk of claim denial. How can you be sure whether a procedure or medication requires prior authorization? It usually behooves a practice to understand an insurer’s minimum authorization requirements and exceed them, but most errors occur when this information isn’t explicitly sought or documented in great detail, or if this information isn’t organized well enough to follow the patient’s record through every step of the billing process. However, this also offers a chance to improve your office’s authorization algorithm by employing an online system that vastly improves accuracy compared to hand recorded authorizations, or outsourcing this and many other complicated billing tasks to outside medical billing experts like Delphi Management Services.
Monitor Insurance Eligibility
Insurance eligibility seems the most straightforward aspect to get right: a patient is insurance eligible or not. So why is insurance ineligibility the cause of so many claim denials? The major reason is usually with return patients whose insurance eligibility has lapsed, or the insurance policy has changed and the patient has not informed the practice of a change in policy. The only way to avoid this is to always confirm the patient’s eligibility is up-to-date with the latest policies before any medical services are rendered. There are a few ways to go about this, but almost all forward-facing solutions involve electronic integration. Set up a specified electronic workflow that guarantees that the rest of the patient’s information can’t be brought forward unless eligibility is up-to-date, and you can ensure you won’t incur a claim denial for this reason. Combine this with a protocol to contact insurers to see if it can be rectified on the spot; it could end up saving you and the patient time and money.
Know Your Medical Necessity
This is becoming a larger and larger source of claim denials. Medical necessity policies are determined by a confluence of recommendations by the Centers for Medicare and Medicaid Services (CMS) and dictate what tests, medical treatments, and procedures can be deemed medically necessary. If these services don’t meet the requirements as deemed medically necessary, an Advanced Beneficiary Notice (ABN) must be issued before services are rendered, or the claim will be denied. If enough of these types of denials accrue, a practice could be found not to be compliant with Medicare regulations. The process for rectifying this can be very complicated because the reasons for a medical necessity claim denial vary greatly. Generally speaking, it is best to try to appeal a claim if the payer has a policy to allow it, and to facilitate clear communication among the patient and the insurer and the medical practice. Otherwise, the practice may be forced to write-off the expense, or worse: issue a discontinuation of medical services.
Employ Accurate Medical Coding
ICD and CPT coding can be the bane of the existence of many medical practices, constituting tens of thousands of dollars of lost revenue for reasons ranging from inaccurate diagnosis coding to improperly coding a new versus returning patient to a CPT modifier referring to one procedure when a payer policy specifically assigns it to another. Medical coding expertise has become such an integral part of a medical practice’s financial health since the migration to EHRs where having experts can be the difference between a practice closing down or thriving. The only real solution to denied claims from coding is to be an expert at it, to know the medical providers’ coding preferences, and to anticipate problems or rule changes with each new update in the world of coding.
These are just 5 ways you can change your practice’s billing procedures to increase your revenue stream and reduce claim denials. Some can be accomplished in-house, but others can greatly benefit from outsourcing your medical billing to experts who remain up-to-date on all of the above best practices like the experts at Delphi Management Services.