Overcoming DME Billing Challenges with a Medical Billing Service

There is a distinctive difference between billing for Durable Medical Equipment (DME) services and other clinical procedures – durable medical equipment services are ancillary to the primary clinical purpose, and their admissibility is subject to certain conditions.  Physicians since long have found these conditions tricky and challenging to understand, and often either been denied or underpaid for DME services, which may either have been

• Deemed medical unnecessary,
• Uncertified by Medicare/Medicaid/private health insurers,
• Beyond the permissible reimbursement level
• Lack of solid grounding in the Healthcare Common Procedure Coding System (HCPCS), which governs level II codes designated for DME equipment and supplies

While physicians have the right to recommend DMEs as part of a clinical treatment, they will have to back their recommendation with sufficient proof of them being medical necessary. Proving medical necessary alone will not suffice; it is equally important to know whether or not patient’s health insurance coverage supports DME services. With Medicare, Medicaid, and even certain private insurance schemes cautious about supporting exorbitant DMEs, physicians would do well to be verify whether or not patients’ health plans support DMEs.

Reimbursements are subject to the condition that physicians or patients source the admissible DMEs from payer-recognized vendors or manufacturers. While this condition may endorse payers’ commitment toward quality DMEs that last long and are competitively priced, physicians will certainly be put through the process of identifying Medicare/Medicaid/private insurer recognized vendors or manufacturers.  What is more interesting is that Medicare has designated certain pharmacies that can only supply admissible DMEs. Therefore, physicians’ task of identifying and sourcing DMEs has certainly become more complex than ever.

DMEs have grown to be clinically superior and functionally perfect these days. While appreciation in quality has facilitated clinical efficiency and patient well-being, price has been a major issue. Payers have not been all that receptive to the idea of supporting DMEs that are not operationally viable. Medicare/Medicaid too has its own reservations against highly-priced DMEs, and has put a ceiling on DMEs reimbursements.  Physicians, therefore, need to be aware of these restrictions while encountering patients that require DMEs well beyond their insurance eligibility.

Lack of solid grounding in the Healthcare Common Procedure Coding System (HCPCS), which governs level II codes designated for DME equipment and supplies, has largely been responsible for physicians’ below par realization of DME bills. In fact, if we revisit payer reports, wrong codes, absence of modifiers and insufficient narration seem to have contributed to drastic fall in reimbursement of DME bills. With care providers transiting to a more streamlined coding practice in ICD-10, DME-relevant codes will further get emphasized.

But for physicians, who are already reeling under a series of health care reforms, DME-related challenges may prove to be simply unbearable.  In-house staff, who are generally tied with clinical duties, may not be able to stretch beyond their general billing capability. The situation prompts an external medical billing intervention that can offer DME billing as part its comprehensive medical billing services.

Medicalbillersandcoders.com has verifiable success in DME billing services for practices across the 50 states in the U.S. The experience of negotiating DME claims with state-specific Medicaid policies, Medicare, and a host of private health plans is itself proof of our competence. With a team of DME billing experts at your service, challenges associated with ascertaining DME necessity, Medicare/Medicaid/private health insurers’ approval, permissible reimbursement level, and Healthcare Common Procedure Coding System (HCPCS) might just be the thing of the past!

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.

Managing Holiday Season Resource-Crunch with the Help of a Medical Billing Company

Healthcare is perhaps one of those few professions which are exception to the general rule of eight hour-a-day duty – professionals are required to stretch beyond their usual duty hours, and may even have to be on a 24×7 vigil. As a result work-related fatigue has been more common, which is undesirable from clinical point of view. Fortunately, holidays offer welcome-break from the rigors of work, and help professionals revitalize their mind and body. Generally, holidays in U.S. are season-driven – most professionals opt for holidays during Christmas.

While professionals can look forward to a long-awaited break this Christmas season, there is something whose rhythm cannot simply be ignored – medical billing, processing and claim realization. But, when the majority of resources – either internal staff or external resources – are expected to be on leave for a considerable period,  a large portion of medical practitioners’ bills may remain unprocessed, unrealized or piled up as account receivables, which are potentially detrimental to financially viable clinical operations.

During such resource-crunch times, medical billing companies – with enormous, flexible and agile resource base – should keep your reimbursements unaffected. While you may have conceded to the idea of outsourcing from medical billing company, you should still arrive upon the best source among many billing companies offering their services. The following factors should help you determine whether or not the medical billing company in question is credible and competent enough to fit into your requirements:

Is the company open to the idea of risk-sharing? Many companies are open to the idea of operating on a risk-sharing model – being able to share operational profit or loss equally with their clients, i.e. medical practitioners. Therefore, it is better your prospective medical billing company is comfortable with this clause.

Will the billing company earmark a separate account representative? Medical billing company manages many portfolios, and a single-contact may not be able to answer queries from multiple clients. Therefore, it is better to know if your prospective medical billing company will be able to appoint an account representative exclusively to look after the affairs of your medical billing process.

Will your billing company pursue denials astutely? Denials if not pursued may end up as irrecoverable. Therefore, it is necessary to know in advance whether or not your prospective medical billing company is credited with astute denial management.

Will your filing be on time? Claim submission if not done on time may well get rejected. It is the responsibility of your medical billing company to keep you alerted about filing deadlines, and knowing that your prospective billing partner is sensitive to filing deadlines really helps.

Will my Practice Management be integrated with EHR? The success rate of reimbursement is often decided by how best your PMS is integrated with EHR system. Therefore, your prospective medical billing partner should be capable of implementing a single and integrated platform comprising both PMS as well as EHR.

Will it offer customization? Outsourcing an entire range of general solutions may not make sense – few processes may be irrelevant or may have to be customized to your billing needs. Therefore, it is crucial to know whether or not your prospective billing company can offer the right mix of services to your practice.

What about its success rate with A/Rs? The credibility and competence of a medically billing company is built around its ability to reduce its clients’ A/R days to permissible limit. Verify your prospective biller’s credentials in A/R management before entrusting your billing management.

Is it familiar with technology demands? Medical billing is increasingly being managed by technology – clinical documentation, billing, coding, claim submission, realization, and reporting are all serially managed over a well-networked real time computing. Therefore, it is important to know whether or not your prospective billing company is sufficiently equipped with these technology demands.

Medicalbillersandcoders.com – being the largest consortium for medical billing services – has demonstrated its worth as reliable, broad-based, and flexible medical billing partner for practices of varied sizes and disciplines. Our intense resource-deployment during times of resource-scarcity has helped practices to keep their reimbursements and revenues unaffected even during holiday season. As practices are about to enter another holiday season, we assure them of everything that they anticipate from an ideal billing partner.

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.

Physicians to Manage Revenues amidst the Impending 26.5% Medicare Cut with a Medical Billing Service

Ever since Sustainable Growth Rate (SGR) began overshooting budgeted Medicare spend, physicians have been under the constant threat of Medicare cut. While Congress’ intervention has delayed the inevitable thus far, it may be a little tougher this time – Centre for Medicare Services (CMS) has already indicated that its fee schedule for 2013 is designed to initiate 26.5% Medicare cut if the Congress fails to intervene before Jan. 1, 2013. While physicians may still be optimistic of a breakthrough in their favor, they still need to be prepared for any eventuality. And if 26.5 Medicare cut is indeed set in motion, it would have a debilitating effect on physicians’ clinical and operational efficiency – practices may not be able to support operational expenditure, leave alone the thought of ‘profit’.

Despite the looming fear, practices can still find ways to off-set the impact of Medicare cut – transition to new payment and delivery models will help meeting the primary objective of improving patient care as well as moving to a higher-performing Medicare program.

Accountable Care Organization (ACO) is one such care model, which will increasingly become mandatory for care providers in the Medicare network. ACO requires physicians to form a clinical network that can achieve optimum clinical efficiency at minimum cost to patients. ACO works on the formula that a clinical network with A-Z medical services can considerably bring down patients’ medical expenditure. While physicians in an ACO get to be recognized for high performance, they also stand to benefit from shared-savings. Moreover, being in an ACO is indeed helpful in building credibility among patients.

The provision of Affordable Care will also help physicians counter the impact of Medicare cut. The significant thing about this reform is that it extends Medicare to every uninsured citizen in U.S. With roughly one-third of population expected to be Medicare beneficiaries, physicians can look forward to off-set Medicare cut with operational volumes from Affordable Care provision.

But transiting to these novel care models may be seemingly difficult for physicians who have been used to protective health care models. Amongst possible challenges, understanding fee schedule, negotiating and renewing payer contracts, being conversant with multiple payer policies, and striking beneficial deal with payers will be more important. Moreover, a proper mix of public-private payers is more than advisable.

And, amidst these Medicare-cut-generated challenges, mandatory EHR, PQRS, and ICD-10 & HIPPA 5010 compliant coding too will add to the burden, which may be far too much to bear for physicians. With the in-house staff incapacitated to take responsibility of this enormity, outsourced medical billing services seem to be the only way out. Medical billing companies – with experience and competence in stage-managing transformation to high-performance Medicare models, managing mandatory EHR, PQRS, and ICD-10 & HIPPA 5010 compliant coding on behalf of physicians who are essentially focused on clinical efficiency – could provide helping hand.

Medicalbillersandcoders.com has time and again demonstrated its worth as being most reliable, flexible and transformation source for physicians’ billing and operational issues. Over the years, we have successfully helped practices of varied sizes and disciplines ease through operational hurdles. And, at a time when physicians are confronted with the impending 26.5% Medicare cut, we are committed to help them counter the impact with alternative and profitable operational practices. Our broad-base of resources – comprising competent medical billing professionals, who are conversant with dynamics of Medicare and other payer systems – essentially drives our mission across all the 50 states in U.S.

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.

Correlation between Practice Revenue and Operational Documentation

Documentation holds special significance in clinical care – care coordination, easy reference, clinical research, and clinical certification are all made possible by well-documented clinical encounters. But documentation got a new dimension when fee-for-service was first replaced by Medicare-supported reimbursements. And, with the gradual inclusion of private players in health insurance, the significant of documentation is felt operationally too – documentation is the single-most source for billing, coding, and verifying the accuracy of claim submission.

Over the years, there has been considerable increase in both incidence and volume of documentation – increase in insurance-backed patients has largely been responsible for this. As a result, staff’s documentation responsibilities too have gone up. What used to a few demographic entries, insurance eligibility verifications, charge entries, billing, coding, submission and follow ups, has suddenly assumed gigantic proportions. And, when internal staff is forced to manage beyond their capacity, issues such as delay, denial, resubmission, audit, and arbitration are bound to be common. The fact that physicians find themselves in multi-payer system – which continues to be tougher by the day – is reason enough to practice accurate documentation so as to be operationally viable.

EHR provides the right platform needed to respond with operational documentation as required by your payers. As an EHR is capable of integrating clinical documentation with Practice Management System (PMS), billing and coding errors will be more unlikely. Further, with the capacity for large data base, EHR can be relied upon for any future reference or audit verification from payer side. Significantly, EHR is supposed to be a primary requirement for ensuring patients’ privacy and security as mandated by HIPAA 5010.

EHR-enabled documentation will be more than just a requirement as practices continue to negotiate economic uncertainty, declining reimbursements, healthcare reform and an increasing emphasis on performance improvement. While the imminent ICD-10 regime promises streamlined billing practices, physicians will have to do whatever best they can to have a documentation system that is consistent, comprehensive, and accurate enough to be translated into ICD-10 compliant billing and coding. Practices that lack the will and resources to adopt progressive EHR-enabled documentation may well lose considerable chunk of patients as well as practice revenues.

Therefore, medical practices have the ominous task of either find the solution themselves or with an external intervention – billing consultants or companies. The complexities involved in customizing operational documentation as demanded by individual practice structures make it apt to outsource from credible and competent sources. Medical billing service providers with strategic partnership with leading EHR vendors may just be the people to bank upon.

Medicalbillersandcoders.com is known to have implemented customized EHR systems as part of its comprehensive RCM services. Practices of varied sizes and disciplines across the 50 in U.S. have experienced clinical and operational utilities from our EHR implementation. And, at a time when medical documentation has begun to impact operational revenues, we are leveraging our internal competence (experts in EHR implementation) with external collaboration (leading EHR vendors or manufacturers) to set up revenue-promoting documentation systems.

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.

Financial Stability from Collaborative Partnership with Billing Companies

Business acumen is something that is generally lacking amongst health care professionals, particularly doctors or physicians. Physicians are primarily driven by clinical excellence, which they believe it to be pivotal to their existence, growth and credibility amongst the patient community. True, clinical excellence continues to be decisive factor even today. But, in a free economy where quality is generally standardized, practitioners’ financial stability and growth is not determined by clinical excellence alone, but innovative care, strategic expansion, and more importantly effective & efficient medical billing as well.

U.S. health care sector has always been at the fore-front of clinical innovations – adoption of improved clinical practices and technologies continue to enrich clinical experience and outcome. It is unquestionably true that patients are increasingly drawn towards practitioners with innovative attitude. As a result, many practices that are incompetent to reinvent themselves may slowly be on their way out.

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Practice expansion too is something that is generally neglected by physicians – many are happy with single-outlet practice. But it is quite possible that competition may gradually reduce what once used to be profitable practice to a loss-making one. To offset such adverse impact, it is prudent to think of expanding your practice base to regions with positive growth prospects.

Billing complexity is a major reason for practices’ financial woes. With fee-for-service completed replaced by health insurance reimbursements, physicians have entered a multi-payer environment characterized by region-specific rules on Medicare and Medicaid, diverse fee-schedules, and overtly strict reimbursement policies. As a result, delay and denials continue to pile up account receivables and erode practice revenues. 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; and medical practices never pursue 18% of claims at all. While payers (whether Medicare, Medicaid or private health insurance companies) are justified in refusing or withholding claims with inherent billing and coding errrors, physicians could still have averted revenue loss of this magnitude with collaborative partnership with billing companies.

Maintaining financial stability will be even more challenging post the series of recent health care reforms – Medicare cuts, affordable & ACO model of care, mandatory EHR compliance, HIPAA 5010 compliant patient privacy and security, and ICD-10 based billing & coding.  If Medicare cuts are indeed brought on, physicians will have to forego a considerable portion of their reimbursement.  ACO model of care too is designed to rationalize reimbursement. While mandatory EHR compliance, HIPAA 5010 compliant patient privacy and security, and ICD-10 based billing & coding all promise to streamline medical billing practices, compliance will not come about without investing on people and technology.

The possible loss from Medicare cuts will have to be off-set with increase in volumes or being eligible for lion’s share in incentives from ACO model.  More importantly the capital investment on people and technology needs to be recouped as early as possible if practices wish to remain profitable. All these finer aspects of financial management may prove to be beyond physicians’ capability, whose scope is limited to clinical management. Therefore, medical billing companies – with experience and competence in advising physicians of profitable practices, negotiating higher fees schedule with payers, setting up contract with multiple payers, and more importantly streamlining business practices with coding & billing accuracy – should assume the mantle of financial management.

Medicalbillersandcoders.com has already proved its worth as a reliable medical billing and financial management partner to practices of varied size and specialization across the 50 states in the U.S. We are well-served by a team of expert medical billing professionals with expertise in finer aspects of financial management for care providers. Their familiarity with multiple payers, government agencies, and prominent knowledge & technology sources gives us a distinctive edge when it comes to managing practices’ financial aspect.

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.