Whether you're a small doctor's office or a regional hospital, revenue cycle management is a huge issue healthcare providers have to take on. Let's put the stethoscope to the financial heart of your business.
Billing the right codes for services rendered can be a tedious process. Undercoding is when a lesser service is billed for than what was actually performed and is a practice many providers fall into. This means less money comes into the clinic than what is deserved, however, these are usually paid as submitted without question from insurance. Providers are more willing to lose revenue than be subject to an insurance audit.
Overcoding is when a higher service is billed for than what was actually performed. Sure, more revenue comes into the clinic but over time, insurance companies will become suspicious and the chance of a post-payment audit is more likely.
The healthcare provider will need to find the sweet spot and they can only attain it in playing by the rules: Billing the correct code for what was performed, and sending accurate medical documentation to insurance as proof.
Verify Patient Information
This cannot be stressed enough. In a 2016 Change Healthcare study, about 24% of denied claims were due to errors in registration and eligibility verification. Patient information absolutely needs to be recorded prior to the office visit, not the day of. Not only patient information but the subscriber information needs to be verified as well.
In most cases, patient and subscriber information are one in the same, however there are occasions when the patient is dependent on a plan with another's name (the subscriber). If that is the case, the subscriber's name needs to be on the filed claim or else it will be denied. For example, a 22 year-old could give their college apartment address, when actually the address matching the health plan is that of their parent, the subscriber. Having to chase down a patient for proper insurance after the service is performed is detrimental, both as lost revenue and as a continued expense for staff spending time calling patients.
Sometimes the best way to utilize a health insurance plan is not utilizing one at all. Treating self-pay patients completely bypasses use of insurance and is revenue the doctor's office sees immediately, and not 3 months later. This is especially helpful when patients have high-deductible health plans (HDHP) reserved in case of a catastrophe. Additionally, patients may attempt to submit a receipt to their insurance to have that cash payment apply towards their deductible.
Clinics accepting cash payment for doctor's appointments and accompanying services can see a reduction in the insurance-induced headaches and an increase in their bottom line.
With MIPS & MACRA underway, the quality of provider care is under heavy scrutiny with payment correlating to improvement in patient health. Especially so with the heavy weighting on quality of care provided to the patient, compliance testing for prescribed medications is the best way to for sure know what is in your patient's system. If a patient veers from the treatment plan, compliance testing is your assurance you've done all you can as a healthcare provider and states your case for receiving the reimbursement you deserve.
At all times, have everything on hand:
- Accurate, up-to-date medical records
- Evidence of medical necessity
- An electronic document management system or EMR
- Contact information for all referral sources
Be prepared for an audit, even if your practice is squeaky clean.
The Bottom Line
Certainly, all these points are easier said than done. It could take a billing consultant to ensure proper codes are used when filing claims, or implementing an insurance eligibility verification system rather than calling payors and being placed on hold. The point is spending time and resources getting into the weeds, can prove to find some green.
However, compliance testing is the simplest of these to integrate into a practice as it requires just a urine specimen and marked order form to run a robust panel of diabetic medications, blood pressure medications, statins, anticoagulants, opioids, benzodiazepines and more.