How Radiologists Can Refine Their Revenue Cycle Management (RCM) With Radiology Billing Specialists

The emphasis on Revenue Cycle Management could never have been so high as it is now – as radiologists begin to comply with of the Affordable Care Act’s (ACA) requirements, they would realize the importance of reinvent their billing and revenue cycle management process to suit the bundled care, shared risk, and quality-driven reimbursement models. With fee-for-service likely to be phased out in favor of value-based service model, radiologists’ revenues may be vulnerable to reductions or long hold-up at the hands of either public plans such as Medicare, Medicaid, or commercial payors. In fact, the population health management requires diagnostic radiologists to adopt shared-risk model with in a period of five years or so. Therefore, radiologists will be under the obligation to coordinate and conform to performance standards for diagnostic services, rendered to both Medicare-supported beneficiaries as well as commercial insurance beneficiaries.

While displaying the requisite level of diagnostic competence may qualify them for value-based reimbursements and incentives, it is no guarantee that they automatically get converted to monetary returns unless they have substantially modified their medical billing and RCM process to the demands of value-based reimbursement model. Notwithstanding radiologists’ internal billing resources, it may not be possible to maneuver through a more regulatory payment environment without an exclusive third party diagnostic radiology Revenue Cycle Management specialist or specialists. The advantage of having such specialists onboard your Radiology Billing and RCM is that they prove catalytic in the entire process of RCM cycle, comprising:

Credentialing with inclusion of turnkey services, payer enrollment and contracting, credentialing and verification services, state medical licensing services, and personalized attention for individuals or group radiologists

Patient Access with key demographic patient information – including name, social security number, and insurance coverage – to serves as the foundation for payment of services. It is critical that this information be accurate, and linked to other billing functions from centralized registration or pre-registration systems.

Accurate and timely charge capture to make sure that all radiology services produce payable claims; it may be remembered that reconciliation of procedures-to-charges will help confirm that an accurate number of claims have been generated.

Coding powered by automatic and electronic coding of ICD-9 and ICD-10 codes, supervised by trained coders that specialize in CPT, ER and E&M coding

Billing, complete with electronic claim submission, posting denials and aggressive follow up of delays and denials

Collection with emphasis on conversion of older account receivables first and within the permissible time limit.

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As radiologists seek to uplift their revenue fortunes with Radiology Billing Specialists, Medicablbillersandcoders.com offers to mediate the employment of radiology billing specialists, who are capable of:

• Keeping reimbursements as per negotiated fee schedules with Medicare, Medicaid, or commercial health insurance carriers
• Guaranteeing payment contracts as per prevailing market
• Minimizing A/R days through complete and timely charge capture
• Enhancing payment accuracy with line-item posting of charges and payments
• Averting risk through the industry’s most comprehensive compliance program

Efficient Billing Practice to Aid Physicians amidst Continual Coding Revisions, and Avert the Possibility of Denials

Amongst the possible reasons for denials, coding inadequacies seem to have a major impact. Because codes quantify and qualify physicians’ medical services for medical reimbursements from payers, any inherent coding error, miscoding, over or under-coding can lead to denials upon found to be incongruent with acceptable coding practices. While a few coding manipulations may happen intentionally, most of the time it is the complexities of coding that often expose physicians or their staff to coding errors. With revisions made to CPT and HCPCS Level II codes every year, coding-related complexities are destined to multiply further. Failure to discern and apply revised coding systems may eventually result in disqualification or outright Denial of Physicians’ claims. As a result, physicians may have to forgo a considerable chunk of their revenues in the absence of remedial measures.

Even as most of the physicians have some form of in-house medical billing that addresses coding demands, the growing coding revisions and complexities require much more than simple form of in-house medical coding. It really takes an efficient medical billing management to monitor and resolve coding errors and denials. The value of such efficient medical billing management is that it can:

Renew your encounter forms or super bills and systems (where codes are stored and used for claim submission) as and when coding changes are announced.

Update physicians’ internal clinical documentation in a way that best suffices the demands of evolving coding revisions or changes.

Apply revised CPT coding guidelines to validate and minimize the risk of denials. It is noteworthy that such instant adherence to coding guidelines will naturally be appreciated by payers, which may be reflected in fewer audits and denials.

Bargain for better fee schedules based on revised reimbursement rates for the new and revised codes.

Help understand and respond to payers’ payment policies towards revised codes, establishing medical necessity of a medical service, and clinical reporting.

Employ National Correct Coding Initiative (NCCI) edits while resolve the bundling of codes.

Parallel to these comprehensive medical billing management initiatives, it could also monitor and resolve denials through:

• Payer-specific report generation of denials using Review practice management system (PMS).
  
• Discover the main reason behind denials, and resubmit claims with requisite modification and correction to codes.
  
• Supporting the applied codes with solid proof of medical necessity of medical services
  

As physicians across the U.S. seek to adapt to evolving coding revisions – of which ICD-10 alone will have 70,000 odd PCS codes, it may seem difficult without experts’ intervention.

Medicalbillersandcoders.com has effectively positioned to play the role of a facilitator during this phase of coding transformation. Our affiliation with medical billing specialists – competent and experienced to bring about systematic elevation in physicians’ coding practices – should help physicians respond to the challenges of continual coding revisions, and mitigate the possibility of denials as far as possible.

Responding To Growth-Induced Orthopedic Medical Billing Needs with Specialist Intervention

Orthopedics have been on upward growth trajectory thanks to a host of conducive factors – continued pro-orthopedic Medicare reimbursement reforms, innovative care procedures, breakthroughs in orthopedic technology and anesthesia administration have largely been responsible for upsurge in practice volumes. The combination of these factors has enabled shifting orthopedic from hospital-based inpatient form to a more popular and affordable form – outpatient or ambulatory settings. It is noteworthy that this form of orthopedic care is currently growing at over 20%, which is comparable with other fastest growing specialties.

While orthopedic practitioners have reasons to be upbeat about their practice prospects, they should equally be cautious and prepared for billing complexities that may be accompanying the swelling practice volumes.

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One of the primary reasons why Orthopedic Billing may be susceptible to billing complexities is that orthopedic comprises a broad spectrum of procedures to treat a variety of orthopedic conditions, which are perceived and valued differently by payers. Therefore, it would require orthopedic practitioners to be versatile to respond with orthopedic billing and coding in conformity with individual perception of the payer who they are submitting their claim to. More than mere submission of claims, they should necessarily have a systematic Revenue Cycle Management with comprehensive processes such as coding, charge posting, claims filing, payment posting, A/R follow-up including denial management, and reporting.

Significantly, insurance underpayments, which are more rampant in orthopedic and as high as 10 to 15% of the actual claims, may push orthopedic practices into a state of revenue erosion that could jeopardize their clinical and operational efficiency. As a result, they might have to emphasize on monitoring and minimizing underpayments with an effective process of credentialing, verification, patient eligibility, and proper coding & billing.

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Coding revisions too would substantially add up to Orthopedic Billing woes – with the on-set ICD-10, orthopedic codes will be more complex, detailed, and numerically too many to code a wide array of orthopedic procedures such as bone graft, open surgical partial removal of collar bone, partial repair or removal of shoulder bone, open repair of rotator cuff, open repair of rotator cuff, reconstruction rotator cuff, open repair elbow fracture involving ulnar bone, wrist fracture pinning through skin, open surgical treatment wrist fracture, shoulder scope, repair cartilage tear, shoulder scope, partial removal collar bone, shoulder scope, bone shaving, shoulder scope, rotator cuff repair, injection of lower back joint, and many more. This monumental coding revision might warrant appointment of specialist coding professionals.

The changing orthopedic coding and billing landscape would require, among various other things,

To evaluate where you stand currently as against the projected requirements for a comprehensive orthopedic RCM comprising coding, charge posting, claims filing, payment posting, A/R follow-up including denial management, and reporting.

To earmark resources to monitor finances, and assigning them the responsibility of meeting with patients before admission to pre-collect copays, deductibles and co-insurance amounts, and work out payment plans as needed.

To improve front-end revenue cycle management, comprising checking coverage and verifying patient information before hand.

To facilitate training coders on coding revisions as and when they happen.

As in the case of most busy and critical medical disciplines, orthopedics may also be bound by an overriding clinical focus that may be limiting their exposure to full-pledged orthopedic medical billing reforms. Medicalbillersandcoders.com – having successfully mediated resource-deployment for growth-induced medical billing requirements across the broad spectrum of medical disciplines – offers to replicate it in orthopedics too. With an affiliation with chosen pool of orthopedic medical billing specialists across the 50 states in the U.S., orthopedics can expect to have instant access to specialist medical billing services.

Insurance Underpayments, the Issue That is Plaguing Orthopedic Billing the Most

Insurance underpayments continues to be a major concern for medical practices across the United States; more so for orthopedic surgeons, who, despite serving in a more critical specialty, find it hard to fully recover their medical cost. Because most of the orthopedic procedures happen to be highly expensive, even a marginal percentage of insurance underpayments might turn out to be a major drain on practitioners’ revenue, which could severely spoil clinical and operational efficiency. With orthopedic surgeons’ insurance underpayments touching an all-time high of 10 percent and potentiality to reach 20 percent, it may be time that orthopedic surgeons relooked at their medical billing practices and process, and aggressively track and resolve their underpayments. It is encouraging that significant portion of these underpayments (as high as 7 to 10 percent) can easily be made good with a refined and robust orthopedic-specific medical billing.

While most of the underpayments may be linked to refusal by the insurance carriers, the root-cause may be inherent in orthopedic surgeons’ medical billing policies and procedures: Orthopedic Billing

To begin with orthopedic surgeons may have not been enrolled and approved by insurers.

They may not have taken due diligence in verifying patients’ eligibility for services prior to the actual appointment; there could have been lack of technology integration with practice management system to verify coverage for patients’ orthopedic procedures.

Orthopedic surgeons may have not been cautious in seeing pre-authorization or precertification, in the absence which payers are automatically authorized to reject payments for  procedures and services even if they have been proved to be medically necessary.

Orthopedic surgeons’ staff may have left deductible or coinsurance uncollected from patients.

Major portion of patients may have been Medicare and Medicaid beneficiaries, whose reimbursements are lower than most of the popular commercial insurance plans.

There could have been coding errors (either under-coding or over-coding) due to coding staff’s incompetence. And with orthopedic coding likely to be more complex and vast post ICD-10, the scope for coding may be even more.

There could have been considerable in claim submission, so much so that insurance payers could reject them on grounds of being too late to be accepted.

Lack of denial management too may have been another reason; it takes special expertise to track and follow up denials in a system characterized by multiple payers

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It really takes an effective system to monitor and compare underpayments against contracted fee schedules, be it is Medicare, Medicaid or popular commercial health plans. The reasons for underpayments such as the ones highlighted can only be unearthed through a careful analysis of Revenue Cycle Management processes employed by orthopedic surgeons.

Medicalbillersandcoders.com – which has been a resource center for comprehensive medical billing solutions – can mediate the deployment of resources (orthopedic billing specialists) that offer remedial solutions to underpayment issue plaguing the orthopedic surgeons. Significant of advantage of sourcing resources through our platform is that you will get discover the real reason for a decrease in revenue; problems that should be addressed such as credentialing, insurance verification/precertification, collections, coding, and payer mix; and recognize the reasons for denials and comparing payments to the fee schedule to resolve issues with payers.

The Demands of Value-Based Reimbursement Model to Be Met With Medical Billing Specialists

With many of the healthcare reforms set to take effect shortly or having already been in force, providers may have entered a different phase of operational model, which is called value-based model. The unique feature of value-based model is that providers will get reimbursed for delivering superior medical care at a progressively lesser cost. As the public plans such as Medicare, Medicaid, and most of the commercial plans are likely to adopt value-based reimbursement models, it may be inevitable for providers to shift over or find a balance between fee-for-service model and value-based model in order to sustain profitable clinical practices.

To being with, you have Medicare's value-based payment modifier that will be launched for physicians in groups of 100 or more in 2015. The unique thing about this modified value-based payment model is that it works on the principle of ‘carrot and stick’ theory, meaning physicians may either be eligible for either positive or negative payment adjustment depending on their level of compliance with care quality and reporting. To prepare for the eventual 2015 model, it may even be necessary to demonstrate capability for PQRS reporting, beginning as early as 2013. Furthermore, the performance post 2015 will be significant as most of the value-based returns will start yielding from 2017 based on the PQRS reporting post 2015.

While Medicare and Medicaid reimbursements have already begun experimenting with ACO model as a superior form of reimbursing physicians for their services to public healthcare plan beneficiaries, commercial payers, sooner or later, too will be obliged to adopt modified versions of reimbursements. Therefore, providers will have to plan, be prepared and resourceful enough to realize their reimbursements from both public as well as commercial insurance payers.

As far as planning goes, it should all start with:

Thorough evaluation of payer market to find out what value-based payment opportunities await down the line. It may also be important to know the dynamics of payers’ reimbursement methodologies.

Assessment of your current documenting, coding, and billing practices against the requisite standards, dictated by the changing payment models.

Planning progress to the expected level through a phased manner.

Once you have the plan in place to progress to value-based payment model, providers may actually start implementation with:

Value addition to care delivery: It means minimizing the possibility of recurrence of medical conditions. When providers are able to minimize the recurrence, it would contribute to substantially savings in reimbursements that might happily shared by payers with responsible providers.

Better care coordination: Coordinated care, involving physicians and support staff will likely facilitate better clinical outcomes, which are often deemed fit for specials incentives along with regular reimbursements by payers.

Extending patient reach and engagement: When providers begin exploring opportunities to increase their and involvement, it is definitely going to improve care quality, which is the fulcrum for deciding the value-based reimbursements.

Forming new clinical alliances: The value that clinical alliances bring to clinical quality is really unquestionable and the providers’ success as value-based providers will largely depend on how best they network their clinical services with competent specialists.

As providers find themselves engrossed with value-based clinical activities, it may require a dedicated medical billing to look after the process of documenting, coding, and billing claims for value-based reimbursements.

Medicalbillersandcoders.com – with a nation affiliation with resources (medical billing specialists) that can own and execute medical billing functions on behalf of providers stuck in the process of migrating from fee-for-service model and value-based model – offers to mediate the deployment of competent, experienced and versatile medical billing specialists that could effectively look after the operational side of value-based reimbursement model while providers concentrate on the clinical aspect.