In this blog post, we describe how to fix holes in your physician billing. It is well known that physician billing is a complex process. Less well known are the many “holes” in the process where money can disappear. The best protection from these “holes” is sophisticated technology supported by trained medical billing experts. 

This two-part Money Matters series starts with four ways to fix holes in your physician billing with techniques and capabilities that plug physician billing holes and help providers collect all monies due for each service provided. 

1.      First Time Around: The First Pass Clean Claims Rate informs us of the accuracy with which a medical treatment is converted into a billable event– and also has a direct impact on how fast or even if a provider will receive  all money(ies) due for services rendered to a specific patient. Having the capacity to find and fix simple errors like missing digits in an insurance ID or a social security number – or any other preventable mistakes – helps expedite the process and promotes the best possible financial outcomes. In other words, more money faster. 

At AdvantEdge, every claim goes through sophisticated Claims Editing software to power the submission of clean claims. The result is a first pass claim acceptance rate over 99%.

2. 2.     Heads Up: It’s crucial for a medical billing office to have a system in place to make sure all clinical services performed are captured and appropriately converted into a billable event. As an example, for anesthesia billing, the billing operation should have automated methods that review and compare the anesthesia OR schedule to the records captured in the billing system. This is the only way to ensure that if 100 cases are scheduled, these same 100 cases also get to coding, concurrency review, charge entry and then billed to the appropriate payer or responsible party.

Also, since billing information often comes from a hospital system, e.g. Epic or Cerner, glitches in HL-7 or other files can lead to missing information and result in delayed billing. Sophisticated monitoring and reconciliation processes are  required to identify and correct these errors quickly.  The flow of all of the demographic and clinical information that affects each claim needs to be monitored to ensure that nothing is left behind – and all money due is collected.

AdvantEdge’s Workflow Management Tools track all clinical activity and  time and date stamp claims as they move through the billing process or from one specialist to the next. Even cases that need to be moved out of the flow are tracked and monitored, so nothing is overlooked. 

3.      Keep payer contracts current: Payer contracted rates can be complicated, making it difficult (or nearly impossible) to identify and track incorrect payments manually. And, of course, rates can change annually. To avoid payment errors, it’s essential for a medical billing company to upload current contract rates for all payers into their system on an ongoing basis, and be able to compare payments to those contracted rates to ensure that payers are complying. For example: If the reimbursement rate for a given service is increased by 1.5 percent, it’s important for the system to compare the current contracted rate to the amount paid to the provider. Even the smallest underpayments add up over time!

AdvantEdge’s Virtual Manager system loads the providers payer contracts to make sure payments match allowable amounts at the CPT code level. Where a pattern of underpayment is detected, these claims are re-billed to recoup the missing dollars and payers are notified in order to minimize the issue going forward.

4.       Manage Denials:  Since denials come in many different “flavors” – and require immediate attention – it’s essential for each to be tracked and forwarded to the appropriate specialist, often based on reason code(s). While some denials may be coding related, other denials may involve incomplete documentation or other factors. It’s important to know the reason for the denial, so the issue can be properly addressed in minimal time and corrected at the root cause, so it doesn’t perpetuate.

AdvantEdge’s Denial Management processes automatically route denials to the appropriate specialist who conducts the necessary research and quickly resolves the issue. Where a denial pattern is detected, edits are added or corrections are made on the front end to rectify the problem moving forward. When denials are caused by inaccurate or incomplete documentation, this is a valuable opportunity to educate providers on how to improve their documentation – allowing for quicker and more accurate payments in the future.

These 4 ways to fix holes in your physician billing are important. But beyond powerful technology and skilled billing specialists, AdvantEdge realizes the importance of forging strong partnerships with each of our clients with a focus on communication and collaboration to keep our eyes on the goal – more money faster for healthcare providers. Stay tuned for Part II of this series designed to help physicians plug holes in the physician billing process and collect all monies due for each service provided.