Defeat Medical Claim Denials With Data

Defeat Medical Claim Denials With Data

For many providers, medical claim denials are one of the single biggest drains on revenue. When you consider that working just one denial costs about $25, knowing why claims are being denied and how to prevent them in the future isn’t a luxury—it’s a necessity.

Automation and advanced analytics can take much of the burden off your billing team by helping you identify potential denial triggers, adapt to constantly changing payer guidelines, and uncover actionable trends in your claim data.

Waystar’s Denials by the Numbers:

  • 5-10% average denial rate amount physician practices
  • 90% of denials are preventable
  • 76% of providers say denials are their biggest RCM challenge

[ Note: View or download Waystar’s “Defeat Denials with Data” white paper here ]

Waystar, a partner of EZClaim, integrates easily with its medical billing software, creating a seamless exchange of claim, remit, and eligibility information. To learn more about defeating medical claim denials, or to add Waystar as your clearinghouse, visit this page.


ABOUT EZCLAIM:
EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support. Combined, they help improve medical billing revenues. To learn more, visit EZClaim’s website, e-mail them, or call them today at 877.650.0904.

[ Article and white paper contributed by Waystar ]

5 Medical Coding Challenges That Hurt Revenues

5 Medical Coding Challenges That Hurt Revenues

In the world of healthcare revenue cycle management, there are numerous scenarios that can put a stranglehold on your revenue if you’re not prepared. With the COVID-19 pandemic causing varying degrees of change in inpatient volumes and visits, and telemedicine coming further into play, physicians and their practices are having to quickly navigate the nuances of their financial well-being. A practice may be buttoned up from the time the patient walks in the door, but what happens after the visit will determine when the practice will get paid. This element of the revenue cycle starts with coding. Here are five medical coding challenges that will ruin your bottom line.

1. Coding to the Highest Specificity
Missing data on a claim relative to the patient’s diagnosis and procedure can easily cause a rise in denials once received by the payers, resulting in potentially thousands of dollars in write-offs. Medical coders are responsible for coding patients’ claims to the highest level of specificity, ensuring the appropriate CPT, ICD-10-CM, and HCPCS codes are applied based on the patient’s chart from the day’s services.

COVID-19 and telemedicine are frequently bringing on new codes and code sets, all with different variations and modifiers to make the matter even more complex. Medical coders spend a lot of time researching and learning new codes, but every year – and throughout the year – changes and updates are made. Payers don’t only want to know the diagnosis and the treatment; they want to know the cause as well. The Coronavirus Aid, Relief, and Economic Security Act passed in March of 2020 allows for an additional payment from Medicare of 20 percent for claim billed for inpatient COVID-19 patients, however, it was later indicated that a positive COVID-19 test must be stored in the patient’s medical records in order to be eligible for this payment. Being able to stay on top of codes specific to the patient’s diagnosis at treatment is more difficult than ever before.

2. Upcoding
While code specificity is important, so too is ensuring the claims do not contain codes for exaggerated procedures, or even procedures that were never performed, resulting in reimbursement for these false procedures. This seems logical enough, but upcoding can easily occur as a result of human error, misinterpretation of a physician’s notes, or lack of understanding of how to appropriately assign the thousands of ICD-10-CM codes in existence. To add to the pressure, the Office of the Inspector General issued a plan with objectives to prevent fraud and scams, and remedy misspending of COVID-19 response and recovery funds.

Much like under-coding or not providing enough data on the patient’s visit can create issues, upcoding can be a major contributor to financial loss for a practice. Questionable claims can be denied and sent back for corrections and appeals, but upcoding can have more serious ramifications outside of paper-pushing between coders and payers.

Whether it’s making sure the codes are in accordance with the care provided, understanding the code sets that apply for each procedure, or comprehension of the medical record, refraining from upcoding will help ensure a sturdy and compliant revenue stream.

3. Missing or Incorrect Information
There’s a common theme to coding challenges, and that’s having the sufficient information necessary. This information typically is pulled from a patient’s chart or record of a visit, which is often completed by the attending physician. However, even when a claim is submitted, providing required information relative to the procedure to the payer is critical as well. Situations such as failure to report time-based treatments (such as anesthesia, pain management, or hydration treatments) or reporting a code without proper documentation can result in denials.

Furthermore, information in a patient’s electronic health record may also contain inaccurate information. Keystrokes and other human errors can cause these situations to flare up, and it takes a diligent, thoughtful coder to read between the lines and ensure claims have the appropriate information.

4. Timeliness of Coding
The Medical Group Management Association (MGMA) suggested in their 2018 Setting Practice Standards report that a Primary Care Physician should maintain a claim submission rate of 3.11 days after the date of service, but it is becoming increasingly difficult for practices to sustain anything close to this rate. Constant changes to code sets, an increased focus on submitting claims with sufficient and compliant information, and the requirement to code claims to the highest level of specificity, can easily delay the submission by days or weeks.

Nevertheless, delays in coding and submitting claims can cause major lags in payment and substantial loss in revenue. Insurance payers have statutes of limitations that require claims to be submitted anywhere from 120 to just 60 days after the date of service. Simply put – the more time spent coding the claim, the later it will be submitted, thus increasing the odds that the claim will be denied. Expert coders are aware of this and do everything in their power to get coded claims out the door.

5. Staffing Shortages
However, finding experts well versed in coding claims quickly, accurately and in compliance with the False Claims Act is not always an easy task. As you can imagine, the increasing need for care within the senior population is causing a rise in claim volumes, and trying to find a team of coders who know the ins and outs of complex ICD-10-CM coding can easily cause a bottleneck in the revenue cycle. Health executives expressed their struggles to find talent back in 2015, and some forecasts expect a decline in commercial payments by 2024 to further hamper a C-suite’s ability to manage labor costs. The ramifications of incorrect coding are still a key topic of discussion to this day.

The time has come for practices to begin looking outside of their organization for coding support. How is your practice planning to tackle the coding conundrum? When choosing a partner for your medical coding needs, you need to pick an expert to help your practice stay on target. TriZetto Provider Solutions, a Cognizant Company, has available highly-trained, AAPC & AHIMA certified coders with the experience of getting the details right the first time and understand the importance of coding to the medical practice.

For more information about TriZetto Provider Solutions, a partner of EZClaim, visit their website, contact them, or give them a call at 800.969.3666.


ABOUT EZCLAIM:
EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support. Combined, they help improve medical billing revenues. To learn more, visit EZClaim’s website, e-mail them, or call them today at 877.650.0904.

[ Contribution of the TriZetto Provider Solutions Editorial Team ]

Insights from a Medical Billing Expert

Insights from a Medical Billing Expert

In this interview with a medical billing expert and co-owner of Elite Billing Resolutions, Vicky Greenwood, we talk about dealing with the challenges in owning a billing company, some important skills that every medical biller needs, and the value of choosing the right medical billing software. In our time speaking with Vicky, we focused on topics that will aid, contribute, and help grow the skills of the medical billing community. We at EZClaim believe in highlighting the best practices in the industry and sharing those with the larger community. We encourage you to consider these insights, and then let us know what topics you would like to learn more about.

 

EZCLAIM: When did you get into medical billing?
VICKY: “I started in 1994, and at the time we were working on a dinosaur of a system called, “Signature.” We would have to wait overnight to process the entire day’s work. Then we would return in the morning to see if there were any errors in the batch or denials in the claims, which meant being accurate in entering information was essential. Outside of that, we kept all our paperwork in filing cabinets, and they needed to be sorted and organized by date. If a date was off in the filing system it could take the better part of a day to find a patient’s claim. The difference between then and now is night and day. I am definitely thankful for technology.”

EZCLAIM: Why did you start Elite Medical Billing?
VICKY: “We started Elite Medical Billing because we wanted to be able to directly impact our medical practices with the services we provided, and we wanted the freedom to enjoy doing it for our clients. I also knew that I was experienced in the field, was competent at my job, and enjoyed doing what needed to be done to get practices paid. Once I honed those skills and knew we could do it. We hired a lawyer and an accountant, then formed our company.” 

EZCLAIM: What are challenges in starting a company?
VICKY: “First, you have to understand the value of time management and delegation. You don’t want to bite off more than you can chew. It is good to know when you need to ask for help. Next, you want to find good staff. I look for people who have the right attitude about the job first and have the characteristics to be proactive and work hard. Then, I look for experience in the field, learning if they had hands-on experience with claims, denials, and coordination of benefits is part of that. At the end of the day, my staff are my [company], and fortunately, most of my staff have been with me from the beginning.”

EZCLAIM: Why did you choose EZClaim?
VICKY: “We had a client who needed software and, being a smaller company, we needed cost-effective software with strong tech support. When we searched on Google for “easy to use medical billing software,” we found EZClaim. We were won over by the first phone call. Since then, we have been reminded of how great a decision that we made. The simplicity by which you can enter the information, process new patients, and ‘claim them’ within minutes is invaluable. That combined with the great customer service—that answers our questions most often on the first call with detailed answers—and video tutorial support is why we will continue to use and promote the software.”

EZCLAIM: Are you a member of AMBA and MMBA?
VICKY: “We joined the MMBA and AMBA in 2016 to help us certify our billing company. That process and the training, testing, and materials were amazing pieces of helping us get established and grow. In addition, the expos, webinars, and online support offer an abundance of information. Of course, the annual expos are both informative and a great work trip for team building and fun. We make it annually to the MMBA, but our next big goal is to go to the AMBA in Las Vegas!”

EZCLAIM: Have some final thoughts to offer fellow medical billers and business owners?
VICKY: “As a medical biller and owner, you have to be willing to talk with physicians. You need to show them the vouchers and documentation of your work. And it is important to communicate how they bill and how they can be sure to properly classify to get paid. You need to review what they have done in the past and how they can improve in the future by training staff.”

“You can also add value by making them the good guy and yourself the bad guy when dealing with patients and getting paid. We allow patients to call us directly, we answer the questions, and tell them how much they have to pay—then we forward the call to the office. Remember, at the end of the day, you have to show them the money. They work hard and they deserve to get paid.”


ABOUT EZCLAIM:
As a medical billing expert, EZClaim can help the medical practice improve its revenues since it is a medical billing and scheduling software company. EZClaim provides a best-in-class product, with correspondingly exceptional service and support. Combined, EZClaim helps improve medical billing revenues. To learn more, visit EZClaim’s website, email them, or call them today at 877.650.0904.

Modernizing Medical Billing Payments

Modernizing Medical Billing Payments

How to Modernize Your Medical Billing Payments Now

It is now very important to modernize medical billing payments capabilities since upwards of 80% of medical services that don’t get paid by insurance, never get paid!

Are you tired of providing medical services and not getting paid? Have you billed patients for their medical visit or co-pay just to find out that the bill showed up in collections? Are you looking for a better way to use modern technology to increase the number of medical claims being paid on time?  If you own a medical practice or work in the medical billing industry, then chances are you have answered each question with a hearty Yes!

 

Last month, medical billing industry leaders came together to discuss how medical practices can streamline their payment systems and integrate credit card processing into their billing system. [ Participants: Dan Loch (VP of Sales & Marketing, EZClaim), Tony Peterson (VP of Business Development, BillFlash), and Michael Jones (Payment Services Analyst, FullSteam) all joined host Susan Martinez (Sales Consultant, EZClaim) ].

[ Click Here to LISTEN to the Exclusive Podcast ]

Medical Billing Payments Podcast

[ Click Here to VIEW the Exclusive Video ]

KEYS That Came Out of the Discussion:

• CHANGING SYSTEMS AND PROCESSES: The practices that are winning in the payment collections game, and seeing the highest percentage of claims paid, are the offices that have updated their systems from the old school and traditional forms of payment collection to the modern, state-of-the-art systems with payment integration. Plain and simple, this means first educating the patient from the moment they walk in the door and streamlining your payments into one medical billing system to prevent human error. [ Click here to LEARN MORE ].

• STREAMLINING CREDIT CARD PROCESSING: Practices often have jumped headlong into credit card processing by using simple systems with variable fees like Square or Stripe. The problem with that is two-fold: First, understanding processing fees, and secondly, avoiding the errors that occur in the steps of processing those purchases over to the billing record. However, now EZClaim’s medical billing software has an integrated payment featurewhich streamlines the billing and simplifies the fees. [ Click here to LEARN MORE ].

 

These are only a few of the very informational topics that were discussed during this podcast. If you are interested in learning how your practice can put these systems in place, increase patient payments, and simplify your billing process in your office, then click here to listen to the podcast and prepare to learn some new,  up-to-the-minute ‘insights’ on modern medical billing systems. 


ABOUT EZCLAIM:

EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support. Combined, they help improve medical billing revenues. To learn more, visit EZClaim’s website, e-mail them, or call them today at 877.650.0904.

New Year, New Codes: Medical Coding Changes For 2021

New Year, New Codes: Medical Coding Changes For 2021

With a new year comes new medical coding changes.

After the examinations, x-rays, and surgeries, lives another major part of a physician’s day that happens behind the scenes. All the hard work needs to be processed through a successful claim submission, meaning that ultimately earning payment all boils down to one thing – coding. Evaluation and management codes, or E/M codes, are codes a physician uses to report a patient visit. This administrative task – a necessity for any physician – is often cumbersome and prone to errors. Most importantly, it uses up valuable time that could be better spent.

How many of us have experienced the “hurry up and wait” scenario? The type of appointment where you wait in a waiting room, then wait a little more in the exam room, then eventually get 10 minutes with your doctor…only to be rushed out so the next patient can be shuttled in. Unfortunately, it’s all too common. It’s safe to say that many patients could benefit from more face-to-face interaction with their providers.

Many people claim that payment for evaluation and management services is undervalued, specifically when it comes to ambulatory services. Additionally, it’s been argued that the fee schedule itself is not well-designed to support primary care, which requires ongoing care coordination for patients. Pressure existed to increase payment rates for ambulatory E/M services while reducing payment rates for other services. Thankfully, The Centers for Medicare and Medicaid Services (CMS) took notice. With the goal of increasing efficiencies to reduce unnecessary burdens, the “Patients over Paperwork” initiative was established. Per CMS, E/M codes make up 20% of total spending under the physician fee schedule. Part of this initiative aims to reduce the coding and documentation requirements for E/M codes, in turn giving physicians more time to spend with patients. In partnership with The American Medical Society (AMA), CMS worked to revise the rules for evaluation and management coding requirements. These changes were finalized in the 2020 Physician Fee Schedule (PFS) with an effective date of January 1, 2021.

 

So what exactly was revised? The E/M updates affect codes 99201 through 99215 and include the deletion of code 99201 along with revisions to the code selection for 99202 – 99215. Below is a summary of the revisions to E/M codes:

  • Elimination of code 99201
  • Decrease the burden of coding requirements
  • Decreases the burden of documentation
  • Decreases the need for audits
  • Revises the definitions for Medical Decision Making (MDM)
  • Revises the definition of time spent with the patient to total time including non-face-to-face for E/M services by a physician and other QHP
  • Requires a history and/or examination when medically< necessary
  • Offers a clear time ranges for each code for time spent with the patient
  • Addition of a new 15-minute prolonged service code
  • Clinicians will choose a code based on MDM or total time

 

These changes apply to office visits and other outpatient services. It’s noteworthy that these changes represent the first changes to the E/M codes in over 25 years! More importantly, the changes streamline the coding process, reduce clinician burden, and will allow physicians to put the focus back on patient care.

Billing and coding should always be top of mind, but it can be hard to keep up. This is why it’s critical for physicians, clinicians, coders, and billers to completely understand these changes. To help comprehension, the AMA released a checklist identifying ten steps to help the practices prepare for the upcoming changes that can be accessed here. To learn more about the medical coding changes and the summary of revisions, visit the AMA website.

 

TriZetto Provider Solutions is a partner of EZClaim, and can assist you with all your coding needs. For more details about the EZClaim medical billing solution, visit their website, e-mail their support team, or call them at 877.650.0904.

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Note: This article is not a comprehensive overview and is NOT intended to provide coding advice, rather it is intended to highlight the new changes in effect and the need for physicians to ensure they have received the proper training for the upcoming changes. 

[ Contributed by TriZetto Provider Solutions Editorial Team ]