How crucial are certain adjustments while posting payments?

While it is true that payment posting is merely an exercise of recording the actual claim realized against patient account concerned, in reality its scope extends beyond that.  Far from just being an accounting exercise, payment posting has evolved into an indispensable tool for analyzing and augmenting revenue generation from medical claim realization from medical insurance providers. Today, the quality of payment posting exercise can either make or break your final financial report. Therefore, medical practitioners across the healthcare continuum are beginning to lay emphasis on this pivotal component more than ever before. Consequently, the cash posting or payment entry department if yours is an in-house medical billing practice, or your medical billing service provider if yours is an outsourced medical billing practice should view payment posting not merely as posting of the details contained in the explanation of benefits (EOB) from the health insurance providers, but also charging the appropriate patient’s account and initiate the process for denied claims if the actual claim happens to be far below the expected one. 

But before your medical billing and coding department or service provider can embark on the process of appealing against delay or denial, it is imperative that they look into certain adjustments that are integral to any medical billing fee reimbursements. This could save you from being embarrassed when you actually come to know that you have compared the explanation of benefits (EOB) from the health insurance providers in isolation of certain out-of-pockets expenses, co-payments, deductible, allowable limit, etc. Therefore, it becomes inevitable that medical practitioners heed to following adjustments before they can actually make qualms against under realized claims: 

• Billed Amount, the amount which the physician charges for his medical services.

• Allowed Amount, the amount that insurance company agrees to bear for medical  services availed by its beneficiary.

• Write-off, the difference between the billed amount and the actual amount allowed by the insurance company.

• Participating/Non-participating, being participatory a physician accepts whatever the insurance company offers as payment for his medical services. Whereas, in non-participatory role he can bill the patient for the difference between the allowable and the billed.

• Deductible, the amount borne by the beneficiary before his coverage actually gets effective.

• Co-insurance/co-payment, wherein a primary insurance company shares a part of the payment with the secondary insurance company.

• Balance bill, where in a non-participating primary insurance company pays a part of a claim, allowing the balance on the claim to be billed to the patient or secondary insurance company.

• Out-of-pocket expenses, wherein patient himself meets certain medical-related expenditure – deductible, co-pay, co-insurance and balance bills happen to be “out of pocket expenses”.

• Contract Maximum, wherein  insurance companies earmark the maximum payable amount on certain illness or policies.

• Offset, wherein insurance company recovers previously allowed excess EOB  from subsequent payments. 

When one considers these incidental factors that have a direct impact on the quality of payment posting, which in turn has a direct bearing on the financial reporting, it is obvious that physicians would do well with tried and tested payment posting practices. Medicalbillersandcoders.com (www.medicalbillersandcoders.com), whose payment posting practices are part of its credible medical billing Revenue Cycle Management (RCM) services, should amicably address inherent challenges in payment posting.

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How aging reports aid in realizing Account Receivables

Notwithstanding the importance of flawless coding in maximizing healthcare insurance reimbursements from insurance carriers, it is the Account Receivable (A/R) Management that proves decisive in either making or breaking your chances of mitigating denial or delay of your medical bill claims. Most of the physicians, whose primary focus happens to be quality medical care to their patients, never bother to look into this aspect as long as their revenues are not affecting their operational margins. They kind of trust their medical billing department or outsourced Revenue Cycle Management (RCM) service provider. But, despite their best practices, your medical bills are vulnerable to being trashed in Account Receivables for too long; in fact, so long that you may have to relinquish your chances of resubmission. 

This is precisely where you are drawn to keep vigilance on Account Receivables (A/R) so that your Account Receivables are kept within the 120-day-limit.   The best way to keep track on the age of your Account Receivables is to demand a monthly report from your medical billing department or outsourced Revenue Cycle Management (RCM) service provider. Such monthly reports should aid you in knowing how long your claims are languishing in A/R bracket – 30, 60, 90, 120, or more days. But, having access to aging reports does not mean that they are reliable and acted upon for augmenting the process of claim realization. A good aging report need necessarily exhibit how your Medical Billing revenue management services are matching up to the challenges in follow-up on patient accounts and insurance claims. 

Then, how do you ensure that the reports that you avail of are genuine? Is it practical for you to periodical monitor aging-reports on your Account Receivables? If so how often you need to draw on those reports. Well, the answer is definitely ‘yes’, but not on a weekly or monthly basis for it might impede your clinical efficiency if you are drawn into too much of operational issues. Therefore, ideally you can look to draw on these aging reports at the middle of the year when you can actually track what Account Receivables are slipping into expiry bracket, and speed up the follow-up process on first-come-first-out (FIFO) basis. The significance of FIFO is that it kind of minimizes the chances of your Account Receivables falling into ‘bad debts’ category. 

Once you have decided on drawing on aging Account Receivables in the middle of the financial year, and found out those A/Rs that need immediate attention, it is imperative that you follow up with a comprehensive AR Management for augmenting the process of realizing the A/Rs as early as possible. Usually such A/R Management calls for inclusive approach comprising: 

• Insurance follow up, where in your unpaid and underpaid claims are analyzed and promptly followed up with insurance companies for speedier realization. Every effort should be made to substantiate your claims as genuine and worthy of being realized fully.

• Denial Management, wherein, based on the reasons for denial, your denied claims are taken up for resubmission or appealing with the respective attorneys if the insurance companies concerned refuse to entertain the resubmission.

• Patients follow up, wherein outstanding bills from patients are pursued through individualized tracking of patients’ accounts.

• Reconciliation of credit balance, wherein accumulated revenue is taken for audit to see that every account-related revenue is identified and not duplicated.

• Resolving accumulated and unresolved A/Rs, wherein files are taken up for possible redemption through strategic follow up with insurance companies. 

As these functions would invariably seem monumental to physicians, it is prudent to avail tried and tested medical billing management services from credible outsourced service providers. Medicalbillers andcoders.com (www.medicalbillersandcoders.com) – by virtue of leading Revenue Cycle Management (RCM) provider with an array of RCM services comprising 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), A/R management (insurance and patient), and financial management reporting – may well be your preferential choice.

Towards honest Medicare billing practices

In an industry characterized by the highest level of professional integrity and honesty, it is strange yet true that health insurance related fraud and abuse have reached alarming heights. While the incidence of fraud and abuse are equally spread across the health insurance continuum, it’s more intense in Medicare. In fact, a reliable survey (by the American Society of Business & Behavioral Sciences) puts the cost of such Medicare fraud and abuse at a staggering $700 billion annually, which is close to one third of the total healthcare spend. What is even more frightening is that that 80 percent of healthcare fraud is committed by hospitals, clinics and medical providers themselves! While the Federal Government has set up a recovery mechanism, the percentage of recovery against the eroded Medicare expenditure has been rather dismal – roughly about 5% of the expenditure lost to Medicare fraud and abuse is recovered annually.

While the unscrupulous hands have stood to gain (rather dishonesty), it is the Medicare that has to bear the brunt – the Sustainable Growth Rate (SGR) has grown so monstrous that the Federal Government is on the brink of introducing cuts to Medicare reimbursements. To compound the matter even further, the mandated transition from ICD-9 to ICD 10 could make Medicare even more prone to fraud and abuse. As diagnostic codes will increase from 14,000 to 69,000 and procedure codes will increase from 3,800 to 72,000, there is an undercurrent that more complex the coding system, the greater the opportunity for fraud & abuse.

Although the Federal Government has a stringent policy in place for penalizing unscrupulous intentions, yet the duality of the menace – wherein beneficiaries and providers contribute equally to fraud and abuse – and the unholy nexus between them – wherein they collude for unholy gains – have rather been tougher challenges.

Duality of fraud and abuse of health insurance schemes
Fraud by healthcare providers	Fraud by health insurance beneficiaries
Billing for services that were not provided	Using a member ID card that does not belong to that person
Duplicate submission of a claim for the same service	Adding someone to a policy that is not eligible for coverage
Misrepresenting the service provided	Failing to remove someone from a policy when that person is no longer eligible
Upcoding – charging for a more complex or expensive service than was actually provided	Doctor Shopping – visiting several doctors to obtain multiple prescriptions
Billing for a covered service when the service actually provided was not covered

Left with no alternative, Medicare has introduced radical measures to detect, investigate, prevent, prosecute, and recover the loss from fraudulent and abusive actions committed by providers, members, groups, brokers, and others. Although RAC audits have been able to recover a substantial amount of fraudulently claimed reimbursements, still, a considerable cases find ways to sneak under their nose; the high cost of appointing Recovery Audit Contractors (RACs) – nearly ¼ of the total reimbursement to be audited for fraudulent realization is not helping the cause either. Therefore, suspension and cancellation of practice license and Medicare benefits, legal prosecution have become more viable options.

As Medicare fraud and abuse can land beneficiaries and providers in the legal binds, it is high time that they scrupulously avoid such unholy habits or seek professional advice in case their cases are unintentional. This is where medical billers and coders’ competence will come to fore in aiding them to practice honest Medical Billing Practices. Medicalbillersandcoders.com – by virtue of a long-standing credibility as the leading consortium of medical billing for Medicare-related reimbursements and Revenue Cycle Management (RCM) services – may well be your preferential partner for being immune to legal implications surrounding Medicare fraud and abuse.

The Role of radiology in Hospital Revenue

Radiologists are playing an ever increasing role in hospitals and these deeper involvements are due to numerous factors. The outcomes of such an ever increasing involvement of radiologists in hospitals can bring about positive outcomes not just in the core aspects of medicine and for patients but also in the form of pecuniary benefits in the long run for almost all the parties involved in delivering healthcare as well as the recipient of such health care. Moreover, the fact that in terms of revenue, radiology makes an immense contribution to hospitals; especially in community hospitals where cardiology produces almost only one third of what the radiology services generate makes this specialty lucrative for hospitals. MRI (Magnetic Resonance Imaging) and CT (Computed Tomography – CAT scan) services in the hospital radiology departments are the areas that generate a lot of revenue. However, as the demand from hospitals increase for timely and accurate delivery of services, the workloads and pressures on radiologists is also increasing.

Nowadays, the intense utilization of, ultra-sonography, computed tomography and to a minor degree magnetic resonance imaging to check patients treated in the emergency department has altered the amount and type of work required by radiologists. Technological progress in digital imaging have also facilitated the images created to be processed, operated on and also broadcasted quickly all over the country to be examined concurrently with the broadcasting centre. Moreover, the advance in health IT in the form of EHRs has also has a profound effect on the way radiology services are carried out. A storage space like an EHR may only seem a storage entity but it has immense implications for radiology. It is important to accomplish a competent workflow process during the life cycle of the images and the additional data, and radiology can accomplish this, thus creating quality and positive quantitative results.

Another reason that hospitals can generate more revenue in the radiology department is that there is scope of accommodating many more patients due to short scan times. This fact is important since the number of insured in the country is going to increase dramatically and radiology can cope with such demand and generate more revenue in the future. A simple SWOT (Strength, Weakness, Opportunities, and Threats) analysis of hospitals in the United States would reveal that as far as revenue is considered radiology is one the biggest strengths. However, there are also numerous threats such as new and stiff competition in the form of specialized radiology services that are stand-alone in nature and other challenges arising out of the federal reforms.

The challenges and opportunities for hospital based radiologists and radiology departments do not just stop at IT implementation, increased workload, and the reform compliance. The biggest challenge for hospitals is getting paid for their jobs in an accurate and timely manner. The processes involved in accomplishing this goal of revenue enhancement and generation have also changed due to the reforms. Changes in billing codes from ICD-9 to ICD-10, HIPAA compliance, adoption of 5010 platform and changed insurance policies have made streamlining of these processes very important in light of the future volume and quality that is to be achieved.

To accommodate the amount of billing and coding volume in the future, it is important for hospital based radiology departments to look at outsourcing the departmental processes such as revenue cycle management, denial management, interaction with payers, HIPAA compliance in order to cut costs, free up time and resources for the core aspects of medicine or administration in the hospital. Medicalbillersandcoders.com is the largest consortium of medical billers and coders that offer all the services mentioned above in addition to numerous other value added services helpful for physicians and hospitals.

The Impact of Front Desk Executives on Physician Revenue and Billing

The front office desk executive in a physician’s practice has numerous functions to carry out such as understanding the patients’ information related to demographics and finance which is needed for effective billing, the responsibility of communicating the financial policy, and knowledge of insurance plans involved in the practice among the many other routine functions essential for managing front office tasks. However, some functions that a receptionist or front desk executive may perform are complex; for instance, pre-authorizations which require knowledge of insurance policies and procedures to avoid losses and errors.

The front office executive in a medical practice juggles with many tasks at the same time and these can range from greeting the customer to use of Electronic Health Records (EHRs). Moreover, the executive should also be aware of billing codes such as ICD-10 or ICD-9 along with numerous other aspects such as scheduling of appointments, rescheduling when the patient is leaving in order to keep the practice busy and avoid losses, patient education about basic policies and procedures involved in the practice or the delivery of healthcare, and other physical tasks such as using the office equipment efficiently. However, such multitasking can have an impact on the productivity of the practice with long term negative financial consequences.

Tasks such as preauthorization, patient scheduling and other jobs related to revenue have an impact on medical billing, for instance entering the charges can have a direct impact on the revenue and denial rate for the practice. Moreover, the recent reforms have made numerous changes in the way healthcare is delivered and these have affected the daily routine procedures carried out in a medical practice. A paperless environment, introduction of innovative IT services, changes in insurance policies, and changes in medical billing and coding has made it clear that a receptionist’s work has not only changed in nature but involves adoption of new procedures and policies that involve a steep learning curve. Simply put, the work of a receptionist has increased in quantity and the requirements for higher quality in all procedures are expected to avoid losses or even penalties for medical practices.

The education and training of front office executives has not been as extensive and is not meant for handling complex tasks such as contacting the insurance companies for a pre-authorization procedure or entering charges on the front desk which can lead to errors. With a complete overhaul in the health industry, it has perhaps become important that vital tasks involving revenue should be handled by a specialist who can understand the nuances in the administrative process he or she specializes in.

Medicalbillersandcoders.com is a service that is not only the largest consortium of medical billers and coders in the United States but is also involved in the needs and latest requirement in every process involved in (Revenue Cycle Management) RCM or Denial Management and is capable of handling them in a specialized manner so that errors are avoided and your revenue and productivity is not affected. Moreover, we also offer many value added services such as consultancy, research and providing news and information about various latest aspects of the health care industry.

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