How 2026 Code Changes Will Impact Medical Billing and Coding Software, Providers, and Payers

How 2026 Code Changes Will Impact Medical Billing and Coding Software, Providers, and Payers

Sep 24, 2025 | EZClaim, Medical Billing Software Blog

CPT and ICD code changes happen every year, but the updates coming in 2026 are some of the biggest yet. For providers, billers, and payers, they’ll bring new rules, added documentation, and tighter requirements that could slow you down if you’re not ready.

Most practices are already operating at capacity.  Staff are juggling billing workflows, payer demands, and day-to-day patient care. Adding hundreds of coding changes on top of that can feel overwhelming.

That’s where preparation and the right tools make the difference. With EZClaim’s medical billing and coding software, you can stay ahead of updates, keep your workflows running smoothly, and avoid the costly denials that come with falling behind.

Table of Contents

What’s Changing in the 2026 CPT and ICD Codes?

Every year, CPT and ICD codes are revised to keep pace with how healthcare is practiced. New procedures, expanded definitions of existing conditions, and changes in payer requirements all feed into this process. For 2026, you should expect more change than in most years.

The changes will not be small tweaks. They will involve:

  • New codes introduced: Your billers will need to learn and apply new terminology in their daily workflows.
  • Revisions to existing codes: Familiar codes may no longer mean the same thing, requiring updates to documentation templates and claim edits.
  • Retired codes removed: Outdated codes will no longer be accepted, creating denial risks if they’re still in your system.
  • Stricter documentation requirements: Payers will expect greater detail to support the codes you select.

The challenge isn’t just “knowing the changes”. It’s making sure your processes, training, and tools adapt in time to keep your claims accurate.

How Will the 2026 Code Changes Affect Providers?

As a provider, the bulk of the responsibility starts with you because your documentation drives the entire billing process. Without complete and accurate notes, claims can’t be approved.  In 2026, you’ll face:

  • Greater detail in documentation. Notes that once sufficed with a diagnosis and a procedure code will now need supporting detail. For example, severity, laterality, comorbidities, or social context may all come into play.
  • More time pressure. You’re already balancing patient care, charting, and administrative demands. Adding in extra documentation requirements increases your workload unless your systems make it easy to capture the details upfront.
  • Stronger collaboration with billers. Billing teams will rely on you to provide the details that payers expect. If those details aren’t in your notes, claims will be denied, resubmitted, and delayed. This creates frustration for everyone, especially patients waiting for accurate statements.

What can you do now?

  • Update your EHR templates to prompt you for the details payers will expect. Small adjustments in your EHR go a long way. Adding prompts for laterality, severity, and comorbidities ensures you don’t overlook information payers will demand in 2026. These built-in reminders help you document thoroughly without slowing you down.
  • Train your team of providers on the most common gaps that cause denials. Focus training on the most common documentation gaps that lead to denials, like missing modifiers, unspecified diagnoses, or incomplete severity details. Short, role-specific sessions are usually more effective than long workshops, giving your team practical steps they can apply right away.
  • Work with your billing staff to review denial patterns so you know where documentation needs to improve. Billers see where denials happen most often, and their insights are valuable. By setting up regular check-ins between billers and providers, you can identify patterns like “claims denied for lack of specificity in diabetes documentation” or “denials related to missing detail on post-op care.” This helps you target your documentation improvements where they’ll have the biggest impact.

What Do the 2026 Code Changes Mean for Payers?

Payers will also need to adapt. As new and revised codes are rolled out, insurers must update their own review systems and claim acceptance rules. For your practice, this will create new challenges in dealing with denials and payment timelines.

You can expect:

  • More thorough claim reviews. Payers will look more closely for complete documentation and accurate coding before approving claims.
  • Increased denial rates. Claims that use outdated or incomplete codes will be rejected more quickly, slowing your revenue cycle.
  • Longer AR timelines. Even when claims are corrected, each back-and-forth with payers adds time before you see payment.
  • Strained payer-provider relationships. Frequent errors and resubmissions may create friction, making it harder to resolve issues smoothly.

How to stay ahead: For your practice, the best approach is to focus on clean claims from the start. Submitting accurate, well-documented claims reduces denial risk, accelerates reimbursement, and maintains strong relationships with insurers. 

Overall, the key is to stay proactive. Keep your billing system updated so retired codes can’t slip through, use reporting tools to track denial trends by payer and resolve recurring issues quickly, and train your staff to recognize payer-specific requirements that may tighten in 2026. 

How Medical Billing and Coding Software Simplifies Compliance

The 2026 code changes will introduce more documentation requirements, tighter payer rules, and higher expectations for accuracy. Trying to manage all of that manually, with spreadsheets, paper notes, or outdated systems, puts your practice at risk of denials, compliance issues, and revenue delays. That’s where medical billing and coding software becomes essential.

  • Automated Code Updates Each year, hundreds of new codes are added while others are revised or retired. With automated updates, your team doesn’t have to track these changes manually. As soon as codes go into effect, they’re reflected in your billing system, so your staff always works with the most current data. Retired codes are removed, preventing accidental use that could trigger denials.
  • Real-Time Error Prevention Even experienced billers make mistakes under pressure. A missing modifier, outdated code, or incomplete documentation can derail a claim. Medical billing and coding software catches these issues before submission through claim scrubbing, payer-specific edits, and built-in prompts. This reduces rework, saves time, and improves your first-pass acceptance rate.
  • Better Reporting and Visibility Coding changes often create new denial trends that can be hard to spot without data. With customizable reporting, you can track how the 2026 updates affect your practice by payer, provider, or claim type. Real-time dashboards help you quickly identify problem areas, adjust workflows, and keep your revenue cycle running smoothly.
  • Flexibility Across Practice Types Every practice operates differently. A solo provider’s needs aren’t the same as a surgical specialty clinic or a billing company that serves multiple organizations. Medical billing and coding software adapts to your workflow, allowing you to configure templates, rules, and reports that fit your unique environment. It also scales with you, so the system grows as your business does.
  • Improved Team Alignment Providers, billers, and administrators all play a role in coding accuracy. Software ensures that everyone is working from the same, up-to-date set of rules. Built-in documentation prompts guide providers, while billers benefit from automated claim validation and managers gain visibility into performance through reporting.

By putting EZClaim’s medical billing and coding software in place, you give your team a system that removes the guesswork from compliance, catches issues before they cost you money, and keeps your practice efficient even as the rules evolve.

Stay Up-To-Date with EZClaim

The 2026 code changes will test every part of your revenue cycle. If your systems and staff aren’t ready, you’ll see the impact quickly: more denials, slower reimbursements, and frustrated teams. The cost of waiting is too high. EZClaim’s medical billing and coding software keeps you ahead. Automatic code updates eliminate guesswork. Real-time error checks stop denials before they happen. Customizable reporting gives you the visibility to spot trends and fix problems before they affect cash flow.

With EZClaim, your team works smarter, and your revenue stays protected. 

Frequently Asked Questions

Why do CPT and ICD codes change every year?
They’re updated annually to reflect new treatments, medical standards, and public health needs. These updates ensure billing stays accurate and aligned with modern care.

What happens if my practice doesn’t update coding processes for 2026?
You’ll face more denials, delayed payments, and compliance risks. Outdated processes don’t just slow revenue; they put financial stability at risk.

How does medical billing and coding software simplify compliance?
It automates code updates, removes retired codes, and scrubs claims in real time. With EZClaim’s medical billing and coding software, you submit cleaner claims and protect your revenue cycle.

Medical Billing Analytics: Top 5 Metrics to Review Before Year’s End

Medical Billing Analytics: Top 5 Metrics to Review Before Year’s End

Sep 19, 2025 | Medical Billing Software Blog

As the year winds down, many practices face a common problem: lack of visibility into their revenue cycle. On the surface, claims are being submitted and payments are coming in, but without deeper insight, inefficiencies remain hidden. 

Denials get written off, A/R days creep higher, and collections fall short. Left unaddressed, these issues roll into the new year and weaken cash flow, making it harder for practices to stay financially healthy.

This is where medical billing analytics become essential. By tracking the right metrics before year-end, you gain a clear picture of where revenue is leaking, where processes need improvement, and how efficiently your team is collecting. 

This article uncovers the five most important RCM metrics to review before year-end and shows how EZClaim software makes tracking and improving them straightforward.

Table of Contents

  1. Why are year-end RCM metrics so important?
  2. What are the top 5 medical billing analytics to review?
  3. How medical billing analytics software simplifies reporting
  4. Prepare your practice with data-driven insights from EZClaim
  5. Frequently Asked Questions

Why are year-end RCM metrics so important?

Year-end is the best time to measure how well your revenue cycle is performing. Looking at key metrics now gives you the full picture of how claims, payments, and collections moved through your practice over the past twelve months.

This review matters because it shows you trends you might miss in the day-to-day. Are denials increasing? Are payments taking longer to arrive? Is your team collecting as much as it should from both payers and patients? These answers shape your financial health going into the new year.

Without this review, problems linger. Denials continue, A/R grows, and collections stay flat. A year-end check gives you clarity, helps you spot the gaps, and sets a clear baseline so you can start the new year with stronger cash flow and more control over your revenue.

What are the top 5 medical billing analytics to review?

There are many ways to measure revenue cycle performance, but these five metrics consistently provide the clearest insight into your financial health. Reviewing them before year-end ensures you start the new year with actionable data.

1. Accounts Receivable (A/R) Days

Accounts Receivable Days measure the average time it takes to collect payment after a claim is submitted. Long A/R days restrict cash flow and leave practices waiting on money that should already be in the bank. If your averages are creeping toward 60 or 90 days, it signals inefficiencies in your collections process.

The goal is to keep A/R days under 40. Reviewing balances over 90 days, identifying slow-paying insurers, and improving patient collection strategies can help shorten the cycle. When you reduce A/R days, you free up working capital and create more financial stability for the practice.

2. Denial Rate

While A/R tells you how long money takes to arrive, denial rate shows you how much revenue never arrives at all. Denials are a leading cause of lost income, often tied to recurring issues such as coding errors, eligibility mistakes, or missing documentation. Every denial is more than an administrative hassle; it represents revenue that requires additional time and effort to recover, if it can be recovered at all.

Industry benchmarks recommend keeping denial rates under 5%. EZClaim’s reporting helps you run denial reports by payer or service, so you can identify patterns and correct them. With claim scrubbing support from EZClaim partners, many errors can be flagged before the claim is even submitted, preventing denials at the source.

3. Collections Ratio

Where A/R and denial rate expose weaknesses, the collections ratio tells you how much of your potential revenue you are actually capturing. It compares the payments you expected to receive with the payments you actually collected. A strong ratio reflects an efficient revenue cycle. A weak one shows that too much revenue is slipping away.

To improve your ratio, compare contracted rates against actual reimbursements, investigate underpayments, and strengthen patient payment options. EZClaim’s partner network also offers collections and consulting services, giving practices expert strategies to maximize revenue recovery.

4. Claim Lag Time

Claim lag time reveals how quickly you are initiating that process. This metric tracks the number of days between providing a service and submitting the claim. The longer the lag, the longer you wait for payment, and the greater the risk that a claim will be denied for late filing.

Best practice is to keep lag time within three to five days. Delays often point to bottlenecks in coding or internal workflows. With automation tools that speed up the submission processes, you can reduce lag time, improve efficiency, and accelerate cash flow.

5. Net Collection Rate

Net collection rate is the percentage of collectible revenue your practice actually receives after contractual adjustments. It is one of the most revealing benchmarks in medical billing analytics because it reflects the combined impact of A/R days, denials, and collections.

A strong rate should be 95% or higher. If yours is lower, review patient balances, improve denial follow-up, and address underpayments. EZClaim’s reporting makes it simple to track this metric, while partner consulting and collection services provide strategies to capture more of what you are owed.

How medical billing analytics software simplifies reporting

Manual reporting eats up staff time and often leaves you working with outdated or incomplete data. Medical billing analytics software changes that by giving you clear, up-to-date information you can actually use. Here is how EZClaim makes reporting easier:

  • Full revenue cycle visibility – EZClaim gives you a complete view of your revenue cycle in one system. Instead of pulling separate reports from multiple sources, you see claims, denials, collections, and A/R side by side. That means you can track how money moves from service to payment, spot where it slows down, and understand the full financial picture without wasted time.
  • Dashboards built for your practice – Every practice has different priorities. EZClaim lets you build dashboards that zero in on the metrics that matter most to you, whether it is A/R days, denial rates, or patient balances. With the right numbers front and center, staff can monitor performance daily and make adjustments before issues grow into major problems.
  • Built-in claim scrubbing – Denied claims are costly and time-consuming to fix. Through partner integrations, EZClaim checks claims before submission to catch coding errors, eligibility issues, or missing details. This proactive step reduces denials at the source, shortens reimbursement time, and saves staff from rework that eats into productivity.
  • Easier payment collections – Collecting from patients is one of the toughest parts of the revenue cycle. EZClaim Pay, together with its partner Anatomy, automates key parts of the process – sending reminders, processing payments, and reducing manual follow-up. The result is steadier cash flow, less staff frustration, and a better payment experience for patients.
  • Clear, actionable insights – Reports are only valuable if they lead to action. EZClaim’s analytics highlight problem areas like slow-paying insurers or accounts that are aging beyond 90 days. With this visibility, your team knows exactly where to focus, which makes every hour spent on revenue cycle management more effective.

When reporting is simplified and accurate, it shifts from a back-office task to a strategic advantage. EZClaim gives you the clarity to see where money is lost and the tools to recover it.

Prepare your practice with data-driven insights from EZClaim

Year-end is the moment to take control of your revenue cycle. The practices that succeed are the ones that measure performance, identify weaknesses, and act before the new year begins. That means reducing denials, tightening up A/R, and improving collections now, not months from now when the damage is already done.

EZClaim puts those insights at your fingertips. The software delivers clear reporting on the metrics that matter most and pairs it with partner solutions for claim scrubbing, collections, and automated payment tools. Instead of working with incomplete data or chasing problems after the fact, you have everything you need to protect revenue and strengthen cash flow.

Explore EZClaim’s medical billing software to get ahead of 2026.

Frequently Asked Questions

What’s the most important RCM metric to track at year-end?
While all are important, A/R days and denial rate provide the clearest view of financial performance. They show how quickly you are getting paid and where revenue is being lost.

How often should practices review RCM metrics?
Ideally, monthly, with a deeper dive quarterly, and especially at year-end.

Can smaller practices benefit from medical billing analytics?
Yes, analytics scale to any size practice. Even small offices often uncover hidden revenue opportunities with better visibility.

What if my staff doesn’t have time for manual reporting?
That’s where EZClaim’s automated reporting saves time, reduces errors, and provides real-time visibility.

Essential Features of Billing Software for Medical Companies

Essential Features of Billing Software for Medical Companies

Jan 31, 2025 | Medical Billing Software Blog, Uncategorized

Upgrading billing software for medical practices isn’t about keeping up with the times. It’s an investment into innovative tools that streamline operations, minimize costly errors, and align your processes with industry regulations. Beyond the benefits to your organization, you’ll also be able to provide patients with a smoother, more convenient experience.

In this blog, we’ll show you the must-have features to look for when upgrading your medical billing software. 

 

Why Upgrading Your Software Matters

Outdated billing software is slow to process insurance claims, which delays your reimbursements and disrupts cash flow. At the same time, it increases the workload for your staff – they wind up spending time fixing old errors instead of working on current tasks. And without programs designed to meet local, state, and federal regulations, your practice is always at risk of non-compliance.

You can take control of these issues by upgrading to modern billing software for medical practices. With faster claim and reimbursement processing, you’ll boost your cash flow and reduce the administrative burden on your team. Fewer errors mean your staff has more time for productivity. Plus, your patients will appreciate a simpler billing experience with clear security features.

 

Essential Features of Advanced Billing Software for Medical Organizations

1. Automated Claim Management

Automation helps by instantly checking claims for errors (scrubbing), submitting them, and tracking their status. Clean and accurate claims are more likely to be accepted the first time around, which means you’ll get paid faster.

2. Real-Time Eligibility Verification

With real-time verification, you can instantly check a patient’s insurance coverage to see what’s covered and what’s not. Then, you can use the information to help patients understand which charges they’ll be responsible for. Your patients won’t encounter billing surprises, and they’ll be grateful for your guidance.

3. Comprehensive Reporting and Analytics

Advanced reporting tools track key metrics like outstanding claims, patient payments, and overall revenue. You can set up reports to spot trends and inefficiencies in specific areas of your practice. For example, you could identify which procedures are reimbursed quickly or which insurance companies are causing delays.

4. Compliance and Security Features

Billing software built with HIPAA compliance and data security protects your patients’ sensitive data. Encryption and access controls allow only authorized users to view or edit information. You’ll keep your practice compliant with healthcare regulations, avoid penalties, and uphold patient trust.

5. Patient Payment Tools

Patient payment tools like online bill pay, automated reminders, and payment plans make it easy for patients to pay their bills. Automated reminders help reduce missed payments, and online bill pay allows patients to pay from anywhere. By offering a way for patients to pay their bills over time, you make health care more accessible and affordable.

6. Integration Capabilities

When you update a patient’s information in your EHR, you’ll see the changes automatically reflected in the billing system. Your practice won’t have to enter the same information multiple times, which means staff can focus more on patient care.

7. Cloud-Based Access

Cloud-based software allows you and your team to access billing information from anywhere, as long as there’s an internet connection. Plus, because the software is cloud-based, IT costs are lower, and updates happen automatically. Your team can work remotely when needed, knowing that data is secure wherever they are.

8. Customizable Workflows

Customizable workflows let you adjust the billing software to fit the unique needs of your practice. For example, you can set rules that automatically route claims to the appropriate staff or assign certain tasks based on the type of patient or service. You’ll boost efficiency, reduce errors, and help your team stay focused on high-priority tasks.

 

Evaluating Your Billing Software for Medical Needs

When evaluating billing software, start by creating a checklist based on the essential features discussed in this article.

Key features to include:

  • Automated claim management
  • Real-time eligibility verification
  • Comprehensive reporting and analytics
  • Compliance and security features
  • Patient payment tools
  • Integration capabilities
  • Could-based access
  • Customizable workflows

Prioritize features based on your practice’s specific needs. If you’re focused on reducing errors, look for software with robust claim scrubbing and compliance tools.

You should also assess the vendor’s reliability, compare cost vs. ROI, and test the software in a demo.

Vendor Reliability

Look for customer reviews and testimonials to see how other practices use the software and what they think of it. Check what support and training are available to ensure your team can quickly get up to speed. Ideally, a vendor will have transparent pricing with no hidden fees, so you know exactly what you’re paying for.

Cost vs ROI

Consider how the software can save time, reduce errors, and improve cash flow. The right billing software should pay for itself through improved efficiency and reduced administrative costs. Additionally, make sure the software can grow with your practice without excessive additional costs. 

Demo or Free Trial

A demo or trial is the best way to determine whether the software is a good fit for your practice. Pay close attention to key features like claim management, reporting, and patient payment tools. Assess whether the features meet your expectations and will integrate smoothly with your practice’s workflow.

Elevate Your Operations With EZClaim

Now that you know the essential features of billing software for medical companies, you’re positioned to adopt tools that will boost efficiency, compliance, revenue, and patient satisfaction.

Ready to take the first step? Learn how to reach your goals with EZClaim. Visit our website to explore features.

A Guide to Healthcare Billing Software

A Guide to Healthcare Billing Software

Jan 17, 2025 | Medical Billing Software Blog

Healthcare billing is one of the most critical aspects of running a successful medical practice or billing company. As patient care evolves, so does the need for accurate, efficient, and compliant billing processes. This is where healthcare billing software comes in, providing the tools needed to streamline operations, reduce errors, and improve cash flow.

In this guide, we’ll explore what healthcare billing software is, why it’s important, the key features to look for, and how to choose the best solution for your business.
 

What Is Healthcare Billing Software?

Healthcare billing software is a specialized tool designed to manage healthcare practices’ financial and administrative tasks. Its primary purpose is to automate and streamline billing workflows, making it easier for practices to handle insurance claims, patient payments, and revenue cycle management.

Core Functionalities of Healthcare Billing Software:

  • Automated coding and claim submission
  • Insurance verification
  • Payment tracking and reconciliation
  • Customizable reporting and analytics
  • Regulatory compliance tools

Who Uses Healthcare Billing Software?

  • Medical practices of all sizes
  • Billing companies that manage claims for multiple providers
  • Hospitals seeking centralized and streamlined billing systems

 

Why Is Healthcare Billing Software Important?

Healthcare billing software plays a vital role in optimizing financial and administrative operations. Without it, practices often face inefficiencies, revenue leakage, and compliance risks. Here’s why it’s indispensable:

1. Automating Billing Processes

From patient registration to payment tracking, automation simplifies routine tasks, ensuring smoother and faster operations.

2. Reducing Administrative Burdens

Manual billing can be time-consuming and prone to errors. With healthcare billing software, administrative tasks are streamlined, allowing staff to focus more on patient care.

3. Minimizing Errors and Delays

Software solutions help prevent billing mistakes by validating patient and insurance data. This accuracy reduces rework and ensures quicker payment cycles.

4. Enhancing Compliance

Healthcare laws and regulations are ever-changing. Good billing software includes tools to ensure compliance with ICD, CPT, and HIPAA standards, reducing the risk of audits and penalties.

5. Improving Revenue Cycle Management

With real-time insights into financial performance, practices can easily track outstanding payments, identify bottlenecks, and optimize cash flow.

6. Simplifying Patient Billing

Accurate invoicing, payment plans, and automated reminders improve the patient experience and help practices maintain financial transparency.

Risks of Not Using Reliable Healthcare Billing Software:

  • Increased claim denials: Errors or outdated systems can lead to rejections and lost revenue.
  • Regulatory non-compliance: Non-compliance can result in audits, penalties, and legal issues.
  • Inefficient operations: Manual processes can overwhelm staff and reduce productivity.
  • Negative patient experience: Delayed or inaccurate billing frustrates patients and erodes trust.
  • Revenue leakage: Missed charges and slow claims processing impact financial stability.

 

Key Features to Look for in Healthcare Billing Software

When choosing healthcare billing software, prioritize solutions that include the following features:

Billing Process Automation

  • Automated workflows: Features like claim scrubbing and error correction.
  • Electronic remittance advice (ERA): Ensures faster reconciliation with insurance payers.
  • Electronic billing: Simplifies patient payments and supports credit card processing.

Accessibility and Integration

  • Cloud-based access: Enables secure, remote access from any location.
  • Integrated platform: Centralizes billing, claims, and patient communication.
  • EHR/EMR compatibility: Ensures seamless integration with practice management tools.

Compliance and Reporting

  • Regulatory updates: Adapts to ICD, CPT, and HIPAA changes automatically.
  • Customizable reporting: Offers insights to improve financial performance.

Customer Support and Training

  • Dedicated support teams: Provide implementation assistance and ongoing user training.

 

Factors to Consider When Choosing Healthcare Billing Software

Selecting the right healthcare billing software requires understanding your unique needs and priorities. Key factors to consider include:

  1. Business size and scalability: Choose software that grows with your practice.
  2. Budget: Balance affordability with essential features.
  3. Customization options: Ensure the software adapts to your workflows.
  4. Reputation and reviews: Look for feedback from other users.
  5. Customer service quality: Reliable support is crucial for smooth implementation and long-term success.

 

Partner with EZClaim for Your Healthcare Billing Software

Investing in reliable healthcare billing software is essential for efficient operations, compliance, and financial success. At EZClaim, we understand the complexities of healthcare billing and provide solutions tailored to meet the needs of medical practices, billing companies, and hospitals.

With features like billing automation, cloud-based accessibility, and compliance tools, EZClaim is designed to help you simplify operations and improve cash flow.

Ready to transform your billing process?

Explore EZClaim’s healthcare billing software today—request a demo or consultation to see how we can help your business thrive.

Effective Pre-Authorization Processes to Reduce Claim Denials

Effective Pre-Authorization Processes to Reduce Claim Denials

Oct 9, 2024 | EZClaim, Medical Billing Software Blog, Medical Billing Software Customer Service

Claim denials are a significant concern for healthcare practices, directly impacting revenue and cash flow. 25% of denied claims are due to utilization issues, with many of these stemming from missing or expired pre-authorization codes. Without an effective pre-authorization process, practices face delayed payments, additional administrative workload, and potential financial losses. By implementing streamlined pre-authorization practices, you can drastically reduce these denials, maintain a healthier revenue cycle, and ensure a smoother billing process. 

Here’s how to get it right.

1. Stay Informed on Insurance Policies and Requirements

Insurance policies vary across providers and can frequently change, which makes staying up-to-date on their pre-authorization requirements crucial. Assign a staff member to regularly review updates from major insurers and maintain a centralized resource that your billing team can easily access. This proactive approach helps your practice avoid unnecessary claim denials due to outdated or incorrect information.

2. Verify Patient Coverage and Eligibility Early

One of the most effective ways to avoid pre-authorization denials is to verify patient coverage as early as possible, preferably before the appointment. Verify details such as plan type, coverage limits, and any pre-authorization requirements for the proposed services. This step allows for early detection of potential coverage issues and provides an opportunity to address them upfront, reducing the likelihood of denial.

3. Implement a Standardized Pre-Authorization Workflow

Creating a standardized process for handling pre-authorizations can significantly reduce errors. Establish clear steps for identifying procedures that require pre-authorization, gathering necessary documentation, submitting requests, and following up on pending authorizations. Ensure that every member of the billing and administrative team understands the workflow and knows how to handle different scenarios.

Use technology to support this process by integrating pre-authorization steps into your billing software. By having a clear, automated workflow, you ensure consistency, reduce manual errors, and speed up the authorization process.

4. Ensure Complete and Accurate Documentation

Insurance companies often deny claims due to incomplete or inaccurate documentation. When submitting pre-authorization requests, include all necessary details, such as physician notes, test results, and patient history, to substantiate the medical necessity of the procedure. Keep a checklist of required documents for different services to make sure nothing is overlooked.

A streamlined billing software solution can help you organize and attach relevant documentation, making the submission process more efficient. This can significantly reduce denials caused by missing or insufficient information.

5. Monitor and Follow Up on Pre-Authorization Requests

Pre-authorization is not a one-time task; it requires ongoing monitoring and follow-up. Establish a system for tracking the status of all pre-authorization requests, including pending, approved, and denied requests. Implement a schedule for regular follow-ups with insurance providers to check on pending authorizations.

Efficient billing software can provide reminders for follow-ups and status updates, helping ensure that requests are not overlooked and reducing the risk of delays in the billing process.

6. Train Staff and Emphasize Communication

Train your billing and administrative staff on the importance of pre-authorization and best practices for handling the process. Regular training sessions can ensure that everyone is up-to-date on the latest insurance policies, pre-authorization requirements, and documentation procedures. Additionally, fostering clear communication between the billing team, clinical staff, and patients can help streamline pre-authorization and improve patient satisfaction.

7. Leverage Technology for Automation and Efficiency

Technology is key in making the pre-authorization process more efficient. Using billing software that integrates pre-authorization workflows and insurance verification can greatly reduce manual errors and speed up the process. Look for software solutions that automate parts of the pre-authorization process, like identifying procedures that require approval and generating reminders for follow-ups.

Billing software like EZClaim offers integrated solutions that support practices in managing their billing and pre-authorization processes more effectively. By leveraging tools that automate verification and keep records organized, practices can reduce the risk of denied claims while freeing up staff time to focus on patient care.

Reduce Claim Denials with EZClaim

Effective pre-authorization processes are critical for reducing claim denials and maintaining a healthy revenue cycle. By staying informed on insurance policies, verifying patient eligibility early, implementing standardized workflows, ensuring accurate documentation, and leveraging technology, practices can minimize denials and streamline operations. 

Implementing a solution like EZClaim can further support these efforts, offering the tools and automation needed to manage pre-authorizations efficiently. 

To see how an integrated billing solution can help your practice, book a free demo today.

Medical Billing Performance Metrics You Should Be Tracking

Medical Billing Performance Metrics You Should Be Tracking

Oct 7, 2024 | EZClaim, Medical Billing Software Blog, Medical Billing Software Customer Service

Tracking the appropriate medical billing performance metrics is crucial for practice owners who want to maximize revenue and cash flow. With an estimated $935 million lost weekly in the U.S. healthcare system due to billing errors, it’s evident that monitoring these key indicators is essential. By concentrating on the right metrics, you can pinpoint inefficiencies, minimize errors, and enhance the overall financial well-being of your practice. Here are the most critical performance metrics that every practice owner should track.

1. Days in Accounts Receivable (A/R)

Days in A/R measures how long it takes for your practice to receive payments after issuing claims. A high number of days indicates delayed payments, which can strain your practice’s cash flow. Ideally, the number should be around 30-40 days. Monitoring this metric helps you identify issues with claim submissions, insurance denials, or patient payment delays. By improving processes related to billing and follow-ups, practices can work towards reducing this number.

2. First Pass Resolution Rate (FPRR)

First Pass Resolution Rate is the percentage of claims paid on the first submission. A high FPRR indicates that claims are being processed accurately, minimizing the time and effort spent on rework. It’s one of the most telling medical billing performance metrics for understanding the efficiency of your billing process. By keeping track of FPRR, practice owners can identify areas where coding accuracy or claim submission practices need improvement.

3. Denial Rate

The denial rate is the percentage of claims that are denied by insurers. High denial rates signal issues with coding, patient data accuracy, or eligibility verification. Tracking this metric allows practice owners to pinpoint the root causes of denials and take corrective actions to reduce future occurrences. A healthy denial rate should ideally be below 5%.

4. Net Collection Rate

Net collection rate measures the effectiveness of your practice’s billing process by comparing payments received to the total allowable amount for services provided. This metric reflects how well you collect revenue owed to you after factoring in contractual adjustments and write-offs. A net collection rate of 95% or higher is a good target, indicating that your practice is capturing nearly all revenue.

5. Claim Submission to Payment Time

This metric tracks the time from when a claim is submitted to when payment is received. A shorter submission-to-payment time means that your billing process is efficient, and your practice is quickly converting services into cash. Monitoring this metric can help identify bottlenecks in the billing process, allowing you to implement changes to speed up payments.

6. Percentage of Patient Receivables Over 90 Days

Patient balances that remain unpaid for more than 90 days can negatively affect cash flow. Tracking the percentage of patient receivables over 90 days helps you assess the effectiveness of your patient billing and collections process. A high percentage may indicate a need to improve patient communication regarding payment policies or to offer more flexible payment options.

7. Cost to Collect

Cost to collect measures the total expenses incurred to collect payments, including billing staff salaries, software costs, and administrative expenses. A lower cost to collect is indicative of an efficient billing process. Regularly reviewing this metric can help practice owners make informed decisions about where to invest in technology or training to optimize collections.

Improve Performance with EZClaim Medical Billing Software

Monitoring these medical billing performance metrics gives practice owners a comprehensive view of their billing operations, allowing for data-driven decisions that optimize revenue and streamline processes. By keeping a close eye on these metrics, you can identify problem areas and implement changes to improve the financial health of your practice.

Implementing an efficient billing solution like EZClaim can assist in tracking these metrics effectively. With features designed to optimize billing processes and reduce errors, EZClaim provides the tools necessary for accurate data collection and reporting, empowering practice owners to stay on top of their financial performance. To learn more about how EZClaim can support your practice, schedule a demo today!