Denial Management – Integral to Physicians’ Conquering Reimbursement Challenges While Medical Billing

Denials are responsible for major erosion of practice revenues, and, despite the best efforts, denials continue to assume monstrous proportions. The situation has grown so alarming that:

• Medical practices fail to collect 25% of the money they are owed
• $125 billion is left in the bag as unpaid claims
  
• Only 70% of claims are paid the first time they are submitted
  
• Of those denied claims, 60% are never resubmitted to payers
  
• Medical practices never pursue 18% of claims at all

While payers (whether Medicare, Medicaid or private health insurance companies) are justified in denying claims with inherent errors, it is physicians who are responsible for not pursuing with resubmission and intensified efforts. This is where Denial Management becomes significant.

Denial Management comprises thorough analysis of denials and ways to convert denials into reimbursements. The crucial part of an efficient denial management practice is re-appealing with substantial proof.But the actual process of your denial management starts with knowing the reasons for denials.
Over a period of time, it has been seen that payers base their rejections on the following:

• Registration inaccuracies, wherein either patient’s insurance is not verified or a wrong payer is mentioned or it is difficult decipher patient’s identity
  
• Charge Entry with unacceptable procedure or diagnosis codes
  
• Lack of referrals & pre-authorizations
• Inadequate information about patient
• Claims with code duplication for the same procedure
  
• Lack of substantial proof for medical necessity of a procedure
  
• Inaccuracies in clinical documentation
• Bundling non-allowable items or applying modifiers where they are not permissible
  
• Lack of credentialing

 Once you have known the root causes for denials, it should lead you to analyze the extent of denials as against the actual submission. Practice Management System (PMS) makes it easy for you to track down denied claims. The advantage of having a PMS in your practice is that it reflects the exact payment posting against each of the submitted claims making it easy to identify the under realized or denied claims.

Having known the reason and the extent of denial, it is now time to put your denial management skills into practice. While coding revision and modification set the things in motion, it is the relationship with the payers and adjudicating agencies that would eventually tilt the balance in your favor.

But it has been found out the physicians are either reluctant or do not have time to focus on these denial management skills amidst their busy clinical schedule. The fact that their internal staff too lacks these skills has not helped their cause. Therefore, medical billing consultancies that offer to integrate denial management processes into your medical billing practices should offer the much needed relief.

Medical billers and coders – being a proven medical billing consortium offering quality and result-driven medical billing services – across all 50 states for over a decade with experience in handling a varied payer mix – are known for elevating practice revenues through integrated denial management. To substantiate our denial analysis, we follow these steps carefully:

• Figure out specific causes for the accumulation of the denied receivables. Such denial analysis provides us the characteristics of the denials, and an opportunity to get them resolved comprehensively
• Analyze the financial impact of the denials; our team of expert medical billing professionals is adept at identifying the general pattern and stake of the denials to evaluate its impact on financial returns
• Provide feedback to improve the efficiency through root-cause analysis and financial impact analysis of denials

MBC’s unique integrated approach has helped physicians of varying sizes & specialties by interpreting the reasons for denials, increasing resubmission and realization through instant denial analysis and management process.

For more information visit: Medical Billing Companies

How can A Medical Billing Service Help in Increasing Revenue at Your Practice?

Quality and cost have been inseparable. And, as U.S. health care industry is defined by new quality benchmarks, cost of administering medical services too seems be rising proportionately. While physicians continue to respond with appreciable clinical efficiency, they seem to have lost ways to find sustainable existence and growth. The existence of intense competition has forced them to operate at the most competitive prices, and off-set with volume. But, volume has failed to generate real revenues due to several reasons. As a result, many practices have either been forced to wind up operations or sell off.

One of the primary reasons for disproportionate revenues vis-à-vis actual volume is failed medical billing practices. Physician practices are either incompetent or lack the requisite infrastructure to take on the challenges of medical billing. The presence of multi-payer system too has not helped their cause. Medicare, Medicaid, and private payer environments pose unique challenges, which can be handled only by experts.

Sweeping health care reforms too have contributed to physicians’ billing woes. While reforms have generally been promulgated to streamline health care delivery and billing, physicians have found it tough to adapt to monumental transitions such as mandatory EHR compliance, ICD-10 coding, and performance-linked reimbursement regime or ACOs. There have also been instances of failed experiments on account of lack of expert or outside billing consultancy. The impact of these reasons is reflected in under-realization of claims, denials, and undesirable A/R days.

The solution to these inherent challenges lies in a full-pledged Revenue Cycle Management that can effectively mitigate under-realization of claims, denials, and undesirable A/R days. Physician practices that have been or likely to be impacted with revenue issues on account of internal billing incompetence and Federal Government’s clinical and operational reforms would do well to engage RCM consultancy that:

• Increases revenue collections by ensuring patients are eligible for medical services and verifying pre-authorization prior to the examination
• Allows tracking each stage of a claim or batch from first logged to posted payment
• Vigorously follows up with unresolved claims issues and diligently appeals denied claims
• Evaluates denial rationales and coding errors in order to establish follow-up procedures that maximize recovery rate
• Employs predictive modeling to forecast future revenue streams and support cash flow
• Is compliant with Medicare and HIPAA 5010 norms, and operates on certified EMR platform that satisfies HITECH requirements, qualifying physicians for performance incentives
• Provides unparalleled transparency through comprehensive reporting and web-based tools that let you manage performance

It is also imperative that your Revenue Cycle Management (RCM) provider follows the tried and tested process, which comprises orderly execution of patient pre-authorization, eligibility and benefits verification, claim submission, payment posting, denial management, A/R follow up, reporting, and litigation management.

Medicalbillersandcoders.com – with credentials and expertise in managing revenue cycle processes for physician practices of varying sizes across the 50 states in the United States – holds the reputation of being a leading RCM provider with a comprehensive approach, encompassing  patient scheduling and reminders, patient enrollment (demographics and charges), insurance enrollment (for physicians and offices), insurance verification, insurance authorizations, coding and audits, billing and reconciling of accounts (payment posting), account analysis and denial management (EOB analysis), AR management (insurance and patient), and financial management reporting.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies  in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services  according to their preferences of specialty, city, software and services performed.

Monitoring Potential for Up-Coding Errors in EHR with the Help of a Medical Billing Service

There has been considerable resolve and persuasion from the Federal Government to introduce Electronic Health Record System across the health care continuum. The Health Information Technology for Economic and Clinical Health (HITECH) Act has indeed given much impetus to pace of conversion from paper to electronic medium. The bait of financial incentives and penalties for complying with ‘Meaningful Use Criterion’ or otherwise has done wonders to the overall macro clinical efficiency as well physicians’ operational efficiency. In fact, no one would have foreseen the extent of transformation when the Federal Government first announced its major IT reform in 2009.

One of the significant advantages of EHR is that it has enormously simplified complex documenting during the billing process. As a result physician practices have been able manage higher level coding with far more degree of confidence than before. But, amidst all these catalytic effects of EHR, EHR is also known to have paved for errors that had not been possible with paper documentation. While EHR’s ‘cloning feature’ allows one to copy previous notes to current notes, it could also inherit errors in the previous notes or be filled with information that may not be pertinent to the current visit.

The consequence of such cloning is that it may promote coding inconsistencies or up-coding. While physicians may benefit initially with inflated reimbursements, they may be susceptible to audit later. Therefore, with their credibility at stake, they should see that EHR is utilized for the purpose it is meant for: safe and efficient patient care. Whether EHR errors come from system inadequacies or personnel incompetence during billing, physicians should actively involve themselves in resolving them through:

• Charting reviews while processing bills through electronic systems
• Sourcing EHR systems from vendors who promise what is right for you
• Generating baseline CPT frequency report of your E&M services for each provider before you adopt an EHR
• Evaluating variations in coding patterns
• Reviewing your practice records and looking for evidence of cloning or carrying forward notes on physical exams and patient histories
• Shutting down “auto-coder” if your EHR has one

Practically, it may seem too much to ask of physicians who are primarily motivated by clinical focus. The best recourse is to engage competent EHR consultants or medical billers and coders who offer EHR consultancy as an extended service. Medicalbillersandcoders.com– with an extended capability for EHR sourcing, implementing and monitoring for physician practices of varying sizes and specialties – should practically solve all of your EHR related woes. Our strategic alliance with leading EHR vendors will help you find custom-made EHR systems that make it easy to find out cloning and up-coding even before the claim is submitted to the payers or Medicare/Medicaid.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services according to their preferences of specialty, city, software and services performed.

Combining Medical Billing and Coding to Deliver Maximum Physician Revenue

'Medical billing’ and ‘Medical coding’ may have sometimes been used interchangeably to mean the act of claiming reimbursement from insurance payers, but essentially they are two separate and specialized jobs. Medical coding precedes medical billing, and it is irreversible. While a medical biller is entrusted with far more task than a coder, it is the quality of coding that largely decides the success of medical billing. That is why medical coding is often termed as a ‘specialty’ by itself while medical billing, its ‘sub-specialty’.

Medical coding is based on the descriptive narration of the medical services or procedures done by physicians. The coder assigns appropriate codes based on the physicians’ clinical summaries. Here, he may have to verify with diverse source points to validate the correctness of the physician summaries. Typically, he may have to rely on the transcription of the doctor’s notes, ordered laboratory tests, requested imaging studies and other sources. Such verification is necessary in avoiding denial, delay or exposure of claims to payer audit remarks.

Coder’s general responsibility is restricted to assigning CPT codes, ICD codes and HCPCS codes to both report the procedures that were performed and to provide the medical biller with the information necessary to process a claim for reimbursement by the appropriate insurance agency/s. But he may also be required to audit and re-file appeals of denied claims. In certain cases, coder may also educate providers and recommend the appropriate application of federal mandates and compliance that require providers to use specific coding and billing standards through chart audits.

Medical billing, on the other hand, is a series of activities culminating in ensuring maximum reimbursement for physicians. A medical biller job begins with filing insurance forms in the admissible formats with the payers. He may be required to clarify diagnoses or to obtain additional information so as to substantiate physician claims for reimbursement from payers. Like coder, he should also be familiar with CPT; HCPCS Level II and ICD CM codes to help him better understand the clinical summaries.

Apart from preparing invoices, medical biller may even be involved in rectifying past error on account of coding discrepancies. Collecting payments, making adjustments, interpreting Explanation of Benefits (EOBs), and handling denied claims, and processing appeals are all part and parcel of a biller’s routine.

Irrespective of whether coding and billing are done separately or by the same individual/s, the success of physician reimbursements depends on how best they complement each other. While medical practices used to manage coding and billing as a comprehensive internal function, it later started impacting their core function – clinical efficiency. Therefore, outsourced coding and billing became the accepted practice. And, with the US health care industry embracing its biggest billing and coding transition (ICD-10), along with the other reforms affecting the industry physicians’ reimbursement rates may further be impacted. Therefore, finding competent billing and RCM service providers makes much more sense than embarking on costly in-house practices, which may or may not yield the desired results.

Medicalbillersandcoders.com – with demonstrated ability in ensuring maximum reimbursement for a large pool of physician practices across the 50 states in the US – should be your first choice of billing and RCM services. Capable of maneuvering through multi-payer and ICD-10 environment, our billing services live up to being the most comprehensive with Patient Enrollment, Insurance Enrollment, Scheduling, Insurance Verification, Insurance Authorizations, Charge Entry, Coding, Billing and Reconciling of Accounts, Denial Management & Appeals and Physician Credentialing services.

For more information visit : Medical Billing Blog

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies   in USA & help doctors to shortlist Medical Billing Companies, 

Medical Billing Services  according to their preferences of specialty, city, software and services performed.

Navigating through Regulatory Changes that Dramatically Affect Medical Billing

The limited reach of US healthcare network leaves a large part of American population outside the net of healthcare. This problem has stalked US governments traditionally and to expand the reach of healthcare to make healthcare available to a larger part of US population, successive governments (in varying degrees and as suited their political beliefs) have introduced regulations to make healthcare cheaper for and easily accessible to the care receiver.

In continuity of this tradition, the last few years under Obama administration have been witness to a flurry of regulations. Whilst one can argue that they have addressed the traditional concerns and empowered US healthcare to stand up to the challenges of technology and needs of modern day healthcare, the regulations have also affected the day-to-day healthcare operations carried out by medical practitioners coiling up every treatment procedure with regulatory activities burdening care providers with activities they neither have time nor qualification to perform.

The Affordable Care Act will expand the number of insured people by more than 30 million people. To restrict the increasing cost of Medicare, the act will create a panel of experts to prevent reimbursing for treatments not found effective and create incentives for healthcare providers to offer bundled payment modules to care receivers.

These are indeed very effective measures to take healthcare to lower income groups in the US and reduce healthcare costs, but they throw considerable operational challenges to healthcare operators. The effect of increase in number of insured Americans from a care provider standpoint is quite simple to understand: it will mean more regulatory responsibilities for care providers in way of having to deal with technical details related to billing and coding, using codes appropriately, etc., leading to not just time spent by them on nonmedical activities but also exposing them to the prospect of inaccuracies in preparing insurance claims resulting in claim denials.

However, the bundled payment aspect warrants a deeper look to understand the impact of regulations on day-to-day healthcare operations. A treatment episode is a sprawling affair. It includes various phases of treatment an individual goes through from pre-hospitalization diagnosis through hospitalization to post hospitalization care. Each one is a distinct healthcare activity and traditionally has had separate healthcare fees. Bundled payments club together the different fees associated with each phase of a treatment episode and offer the care receiver one fee for the entire treatment life-cycle, saving him money.

Albeit, this everything-rolled-together approach requires sound coordination among various specialties involved in a treatment episode for data sharing and final pulling together of medical information to prepare claims using appropriate codes for each phase of treatment. Big healthcare bodies have addressed some of these concerns (like internal coordination and easy availability of medical data while preparing claims) by making all the services available under one roof but are struggling with others, like using appropriate codes and spending resources (time and money) on non-medical activities, all leading to low rates of claim reimbursement and revenue leakage. Finding it difficult to withstand the financial onslaught wrought by denied claims and losing patients to big care providers, small operators have aligned themselves with big care providers losing their entrepreneurial independence.

Coping with the changes caused to medical billing:

The irony of this whole US healthcare industry saga is that what has caused this is not a healthcare issue but an administrative one. To handle this issue, a care provider either needs an in-house setup with a strong revenue management system staffed by well-trained billers and coders to handle the entire claim preparation process using appropriate codes and medical details where necessary and knowledge of software platforms to submit the claims electronically to ensure HIPPA compliance or needs to outsource the entire claim administration process to a biller and coder.

Medical Billers and Coders, the largest billing and coding consortium in the US,  has helped care providers in all 50 states of rural and urban US to address these issues helping them to save time and cost, an advantage they can divert to their core business, healthcare, and also share with the customer. MBC’s experienced billers and coders are familiar with all regulatory details and prepare claims with high degree of accuracy ensuring low rejection rates.

MBC can also spruce up your revenue management cycle by pruning up your processes, replacing your old software platforms with new and appropriate ones and training your staff in administrative details as also cross-functional competencies thus reducing your downtime and ensuring the continuity of your billing process in the absence of a staff.

Increasing Revenue through HIPAA Compliant Practices

HIPAA (Health Insurance Portability and Accountability Act), which was first enacted in 1996 to improve the efficiency of healthcare delivery, has come to be recognized as the standard for  electronic data interchange (EDI), security, and confidentiality of all healthcare-related data.  The Act mandates: standardized formats for all patient health, administrative, and financial data; unique identifiers (ID numbers) for each healthcare entity, including individuals, employers, health plans and health care providers; and security mechanisms to ensure confidentiality and data integrity for any information that identifies an individual.

Healthcare providers exchange healthcare data for a variety of purposes: collaborative clinical management, national healthcare planning, and more importantly for medical billing. Medical billing is a series of tasks comprising claims submission, charge entry, denial management, payment posting, tracking of accounts, appointment scheduling and rescheduling, billing and reconciling of accounts, patient enrollment, patient scheduling and reminders, financial management reporting, AR management (insurance and patient),  medical coding audits, insurance verifications; insurance authorizations and follow up of rejected claims. The sum total of these tasks is collectively called Revenue Management Cycle (RCM).

Providers at each of these RCM task are required to follow HIPAA norms. One of such predominant norms is electronic processing of billing and coding in accordance with the HITECH’s meaningful use criterion. Failure to comply may invite mandatory data breach notifications, heightened enforcement, increased penalties and expanded patient rights. The cumulative effect of these impositions may unduly delay claim realization, thereby affecting practice revenues. Providers may even face intense audit and scrutiny, which may be detrimental to their credibility and sustenance in a highly competitive healthcare industry.

Therefore, it is advisable that providers’ outsource proven, web-based framework that allows them to collaboratively manage their HIPAA/HITECH Act compliance initiatives including HIPAA Audits and HITECH Privacy Breach Management using a single, integrated solution. Using such robust system (an integrated EHR with EMR and PMS), they will be able to perform the entire range of clinical and operational functions in sync with the HIPAA norms. Once they have their clinical and operational functions (billing included) on the right track, it will be easier to expect unhindered and fast realization of claims. The advantage of engaging a HIPAA-compliant outsourcing company is that it assures confidentiality of patient and practice information in accordance with the norms laid down by the Health Insurance Portability and Accountability Act (HIPAA). This helps avoid unnecessary litigation and maximize claim reimbursement.

Medicalbillerandcoders.com comes across as a trusted name in HIPAA compliant medical billing and RCM services. For over a decade, we have been helping healthcare providers (across the 50 states in the US) realize maximum revenues through reliable HIPAA compliant practices.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies  in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services  according to their preferences of specialty, city, software and services performed.

Billing “Urgent Care” As It Emerges As One of the Fastest Growing Specialties

Urgent care is fast developing as a viable alternative to what has traditionally been known as “family practice”. The main reason behind this new-found fancy is that physicians can now operate from designated facilities without having to trek around offices, nursing homes, and hospitals. Additionally, urgent care centers are preferred to other similar types of ambulatory healthcare centers, such as emergency departments, and walk-in primary care centers by the scope of illness treated and facilities available on-site. It will not be long before we witness further addition to already 8,700 urgent care centers (UCCs) across the US.

While it is true that practicing Urgent care offers physicians an extended scope and avenue for revenue generation, there are certain criteria (established by The Urgent Care Association of America) that physicians must abide by. These criteria describe scope of service, hours of operation, and staffing requirements. A qualifying facility must treat walk-in patients of all ages during all hours of operation. It should treat an entire range of illnesses and injuries, and have the facility to perform minor procedures. An urgent care center must also have on-site diagnostic services, including phlebotomy and x-ray. Because of this inclusive medical service coverage, Urgent care medical billing has become far more complex than usual. Urgent care physicians will be called upon to deal with:

• Code that allows urgent care centers to code and get reimbursement for the extra expenses involved in providing urgent care services
• Code that allows the urgent care center to receive reimbursement at one flat rate (Global Fees for services rendered at Urgent care centers) for all visits coded with it
• The usage of evaluation and management (E/M) codes as per EMTALA guidelines if it is a Type B emergency department
• Facility codes in urgent care
• National Provider Identifier (NPI)
• E/M Code plus Procedure Code in Urgent Care
• Level 1 E/M Code 99211
• Codes for services rendered during extended hours
• E/M Code + IV injection procedure code

Added to this complex coding is a reimbursement environment which has become more restrictive post a series of healthcare reforms recently. This additional burden of revenue cycle management (RCM) to an already overweighing clinical schedule may impede the very focus of clinical excellence. This is precisely the reason why physicians are turning to specialist billing and revenue cycle management from “urgent care medical billers”. Consequently, there has been an unprecedented demand for billers and coders in this domain.

At a time when the market is still peaking, Medicalbillersandcoders.com – the leading source for specialist billing and RCM services – has taken the lead in supplying the right billing and RCM sources to urgent care practitioners. Spread across all the 50 states in US, we provide experienced billing experts for urgent care billing & RCM for your medical practices.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies  in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Servicesaccording to their preferences of specialty, city, software and services performed.