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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The Impact of Staff Turnover on Physician Medical Billing

Staff turnover in any medical practice or hospital can have detrimental repercussions financially as well as qualitatively when it comes to providing healthcare. However, it cannot be denied that staff turnover or attrition would always be present in any practice or hospital; keeping it in control is important for ensuring long term pecuniary benefits and improving the quality of the service that is provided. There are various reasons for staff turnover and how it affects medical billing and provider revenue and there are solutions to turnover problems that can optimize the quality of care, efficiency of workflow processes, improve Medical Billing and also increase your bottom line. 

Health care systems as well as certain facilities where there is nominal investment in healthcare have grave concerns with attrition and turnover, working environment and wages. Reimbursement might be meager or absent, with staff having no say in the improvement of these conditions of care. Consequently, employees and staff frequently leave the practice or hospital in such conditions, leading to numerous problems in keeping the practice afloat or in increasing your revenue or in expanding the practice or facility also disturbing the medical billing process and revenue management cycle of the practice. The brunt of turnover turns out to be far grimmer when there is a scarcity of competent employees and the health requirements of the population exceed the capability of health human resources. 

The shortage of staff and the high turnover rate in the country is causing tremendous problems in many processes such as in medical billing where the scope of error has increased due to lack of expertise in physician or hospital staff. Moreover, as mentioned before, the demand for healthcare is increasing due to the fact that there would be more than 30 million newly insured Americans and the turnover rates along with the shortage of supply signifies a bad omen for the health industry. The increased pressure to comply with the recent reform guidelines and qualify for incentives offered by the government has also brought turnover into the limelight since it is one of the major causes of financial leakage and soaring costs. 

There are numerous ways and reports that have been put forward by experts to reduce turnover in the healthcare industry. Some of the most significant of these are to create a pleasant working environment, addressing employee issues, rewarding good work, paying appropriate remuneration, and ensuring job satisfaction of employees. However, some of these methods do not always work and there is an urgent need to streamline various departmental processes to brace for the impact of increased demand in the health industry. 

This work of reducing errors in medical billing and coding, error free denial management, HIPAA compliance, and keeping up-to-date with the changes happening in the health industry can only be carried out by specialists in this field who are experienced and can perform efficiently. Outsourcing the various departmental processes can not only increase the quality of your Medical Billing and RCM but also eliminate turnover affecting the medical billing process besides ensuring that you as a physician or provider need not worry about staff turnover and have the time and energy to concentrate on the major aspects of medicine. 

Medicalbillersandcoders.com is one of the largest consortiums in the United States that offers departmental services such as RCM, Denial Management, and consultancy in order to ensure that the staff turnover in your hospital or practice does not have a negative impact on your other processes and the revenue.

The Role of Medical Billing Consultants in Assisting Physicians

The recent dynamism in the healthcare industry has not just revolutionized the way in which various medical processes are carried out but have also led to an explosive information boom due to new policies, regulations and a complete overhaul in the health care industry. The ability of providers and other healthcare professionals to keep up with such changing regulations and policies is becoming increasingly limited due to escalating workload and demand in addition to shortage of supply of providers. Moreover, the steep learning curve required in some aspects that have accompanied the health reform has made it clear that physicians can benefit due to external billing consultancy services as far as their financial and departmental processes are concerned. 

The requirement for external consultancy services arises not just due to the changing healthcare industry trends and increasing workloads as well as reduced time to keep up with the changes taking place in regulations and laws. The huge expenditure and financial losses on a national scale in the healthcare industry also makes it imperative that such fiscal losses be avoided by employing consultancy services that can boost providers’ bottom line as well as assist on a macro level to reduce costs of healthcare. These services can support in achieving regulatory compliance and ensure that provider revenue is not affected due to glitches in complying with policies and procedures in addition to ensuring that billing compliances such as, but not limited to, HIPAA compliance and ICD-10 implementation are accurately achieved. 

The analysis of revenue cycle management (RCM) and providing customized solutions is also a part of RCM consultants. Medical billing consultants can analyze and pinpoint the areas where improvement can be achieved and losses curbed. This type of scrutiny and analysis can assist in preventing errors such as those in registration or pre-verification of insurance coverage and ensure accurate collections in deductibles or co-pays. Moreover, analysis of Accounts Receivables (A/R) is an important part in optimizing the revenue of providers through a holistic approach involving patients, payers and other entities involved In A/R. Moreover, medical billing consultancy service providers have the advantage of specialization and are aware of the financial as well as legal trends in the industry. This advantage of specialization and up-to-date knowledge of changes in the health industry can reduce cash flow problems and provide a complete solution to providers’ RCM and A/R needs. 

Medical consultants can assist in many fiscal sectors as far as provider revenue is concerned and avoid losses, legal actions, and numerous other hurdles arising out of errors or otherwise. For instance, the Affordable Care Act extended the RAC program to Medicaid, Medicare Advantage (Part C) in addition to the Medicare prescription drug program (Part D). In order to avoid RAC audits, medical billing consultants can point out cases when overpayment has been done and avoid complications when it comes to such other technicalities. Medical billers at Medicalbillersandcoders.com can perform all these functions related to consultancy in addition to streamlining processes related to denial management, interaction with payers, and integration of innovative IT functionalities such as Electronic Health Records (EHRs) in order to ensure compliance and also to smoothen out various departmental processes. 

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