Whether you are a person new to medical billing or someone who’s been in the business for years, launching a new medical billing practice can be hard. Understanding the market, connecting with new clients, and knowing how to master your processes are challenges that you often learn as you go. Despite these challenges, it is rewarding to be out on your own growing a new company. Before you jump, let us help you understand some essential keys that you can research upfront and prepare yourself to get one step closer to being successful.
1. ONE BILLING PLATFORM VERSUS MULTIPLE PLATFORMS: First and foremost you must make a conscious decision to either focus on being an expert on an individual medical billing platform, like EZClaim or tackling multiple platforms. There are pros and cons of both: being an expert can make you extremely efficient in your use of the software’s billing and, scheduling features, however, it can also limit your client base to only one set of software users. Whereas having a basic understanding of multiple platforms can allow you a larger base of medical offices while limiting your ability to truly understand how best to serve each individual client’s needs.
Pro tip: Start and master one trusted billing program, and grow your options as your billing business grows.
2. GET CLEAR ON THE CLEARINGHOUSE: A new billing company owner does not want to be held to just one clearinghouse as options are key here. Having the ability to work with any or many would be an essential piece to your billing services, however, you still want to know the best clearinghouses in the business. Understanding which clearinghouses provide the best products and services and being able to recommend those services to your client upfront will make your life easier and their business run smoother. For this very reason, EZClaim has built its software around partnerships and integrations with the best clearinghouses to make working with the one you need easy.
3. COMPLY OR DIE (HIPAA Compliance): The third key to any start-up is first understanding the importance of HIPAA Compliance. Medical billing firms literally can come crashing down with any missteps, mistakes, or misunderstandings of this essential piece of the puzzle. It goes without saying that if you are going to choose a billing software be sure that they have partnerships built around making sure you are protected. You are also responsible to make sure the data is protected so your customer and their patient’s data is safe.
There are many options available out there for your new medical billing practice, and we recommend doing your research. Within that research, you will find that EZClaim ranks very high in performance and comes in at a great price.
Claim denials are the bane of every RCM company. Chasing money is costly and navigating regulations, coding edits, and health plan particularities can frustrate even seasoned billing professionals.
The American Association of Family Physicians puts the average claim denial rate at around 20 percent and reworking a single claim can cost hospitals and offices anywhere from $25 – $118 on average, so the initial validity of every claim is critical. While denial percentages have been dropping – thanks to the technology that allows billers and coders to verify the accuracy of their work and catch the most egregious errors – the reality is you can do better. Use the following seven tips as a starting point to determine how you can maximize revenue by reducing denials.
Recognize that the revenue cycle begins in the front office.
Providing services to patients whose insurance has changed or lapsed will result in denial—even if it’s coded correctly. Make it a point to check your patients’ insurance at each visit, including copays and deductibles. Front-end verification can prevent back-office headaches.
Look beyond the first-pass clean claim rate.
A high first-pass clean claim rate may look great on the month-end statement you provide to your bosses, but what does it really mean? This rather meaningless metric only gauges the percentage of claims that are initially accepted by a payer. It says nothing about the denial rate, which is where the real work begins. Focus on metrics that matter, such as denial rate, collections as a percentage of revenue, or days in A/R.
Learn from your mistakes.
Use denied claims as a learning experience. Why did the claim deny? Some common reasons include a lack of medical necessity, a mismatch of diagnosis and treatment codes, upcoding or unbundling, incorrect coding, and missing/wrong modifiers. Use claim data content with comprehensive edit logic to perform a deep dive into denials. Is the problem an individual coder, clinician documentation, or a certain procedure or treatment type? Understanding the “why” behind every error will help you uncover how the organization can do better.
Examine your workflows.
Your increased denial rate may be occurring because your operational workflows aren’t aligned with billing best practices. If you are performing claim editing only after the claim is generated, you’re not allowing for actionable change by those who created the errors. Also, are those who work denied claims relaying the information back to the relevant department? If your billers, coders, and clinicians don’t know they are making mistakes, they will continue to make them
Edit claims early in the process.
This goes hand in hand with our previous step. Recognize that revenue cycle management truly begins in the front office and flows through everyone who generates a charge, codes a procedure, or prepares a claim. Develop the mindset that everyone who touches a patient record should understand the implications of coding. For example, a clinician who sees charting as a burdensome task may make inadvertent mistakes that result in incorrect coding, which in turn creates more work for your billing staff who has to work the denial. Fixing these costly mistakes takes precious time that would be better spent on more complex tasks.
Examine your claims technology.
Claim editing software is a must to reduce denials. But not all software is the same. As we said before, claims acceptance is important but has little bearing on overall denial rates. Many electronic medical records and practice management systems have generic claim edits that check for obvious technical mismatches such as age-related discrepancies, date of service issues, and CCI mismatches. But those systems will do nothing to help your billing department move the needle on denials. An advanced clinical claim editing solution with constantly updated content is worth the investment. The edit explanations help your coding staff recognize the changing parameters that can affect denials.
Train for better performance.
Not everyone on your staff or in your billing organization needs to understand coding and claims at a detailed level. However, everyone should understand the role they play in the revenue cycle process. Don’t simply demand that front office staff check insurance every time – explain why it’s important to the claims process. Make sure clinicians understand the differences between common visit types and procedures so charges are captured accurately on the front end. And ensure your coding and revenue cycle personnel are working to add value to the organization by performing high-level work. A robust clinical coding and claim editing software can help educate coders on procedural changes and provide tips to keep claim denials as low as possible.
Just as everyone who interacts with a patient affects that patient’s perception of your practice, reducing your organization’s claims denial rate is the responsibility of every staff member who interacts with the patient’s data. Ensuring accuracy throughout your entire revenue cycle will improve the overall integrity and result in improved revenue.
The Alpha II Solution
Are you ready to submit precise claims the first time? Contact Alpha II, a leader in revenue cycle solutions. Our comprehensive clinical claim editing solution, ClaimStaker, covers the entire continuum of care, verifying claim data from the payer’s perspective and allowing for corrections prior to filing.
If you enjoyed this article about denied claims and seven tips to improve revenue integrity, visit our blog page to see more interesting and informative articles. You may also Follow Us on Facebook to stay up to date with our most recent events at EZClaim.
Getting Claims Right the First Time. Contributed by Timothy Mills, Chief Growth Officer, Alpha II, LLC
The numbers are staggering. Industry averages report that nearly 20% of all claims are denied, rejected, or underpaid. And considering the cost to rework claims — not to mention even higher appeal costs — as many as 60% of returned claims are never resubmitted.
With figures like these, it’s no wonder medical practices continue to face intense financial pressure. As negotiated reimbursements stagnate and operating expenses like rent and salaries continue to increase, the struggle to maintain steady revenue becomes even more crucial. For many practices, conducting reviews of their revenue cycle workflow would show gaps in their claims process. The good news is – these gaps can be bridged with the help of emerging technology.
With a saturated market of coding, billing, and compliance solutions, how do you begin to find the right technology for your practice?When trying to improve revenue integrity, it is important to understand exactly what vendors offer. For example, consider the term “first-pass claims rate,” which is still used by some healthcare IT vendors to represent the number of claims initially accepted by payers. But what is often overlooked is the number of those initially accepted claims that will be denied or underpaid. A better question would be – what percentage of claims are getting paid the first time they are submitted?
The fact is, practices that do not employ the latest clinical coding and editing tools within their revenue cycle are leaving money on the table. This is revenue that is rightfully theirs but is being pursued at high, incremental costs. It’s time to rethink traditional denials management practices, move beyond the “first pass claims rate,” and embrace the future of denial prevention.
It’s your money. Go after it.
Still not convinced that investing in emerging clinical coding and editing software can save your practice money? Let’s see what relying on traditional denials management methods might really be costing you.
Each rejected, denied or underpaid claim represents earned revenue your practice is missing out on. Based on industry reports, the average cost to rework a claim has been pegged at more than $25, and appeal costs can skyrocket to over $100. It’s estimated that as many as two-thirds of all denied claims are recoverable. But practices often weigh the reimbursement amount of a claim against the cost to rework or appeal that claim. For smaller claims, many decide it just isn’t worth the effort, which is why getting claims right the first time should be the ultimate goal.
So how much are practices losing by simply correcting and resubmitting denied claims using traditional denial management methods? Let’s look at an example using figures from an actual mid-sized specialty practice. This practice submits 1,900 claims a month and the average claim is $150. They have a better-than-average denial/rejection rate of 10 percent. Even with that lowered rate, this practice is losing roughly $28,500 a month to unresolved denied claims. If two-thirds of those denied claims are recoverable, they stand to recoup $19,095 in reimbursements after the claims are corrected and resubmitted. Factor in the cost associated with reworking denied claims using the industry average of $25 per claim, and this practice is spending $4,750 in administrative charges alone to recover their own revenue. This brings their actual recovered revenue down to $14,155 per month or almost $170,000 annually.Investing in a comprehensive clinical coding and editing solution is still cheaper than what the practice spends per month when reworking denied claims.
The Alpha II Solution
Are you ready to submit precise claims the first time?Contact Alpha II, a leader in revenue cycle solutions. Our comprehensive clinical claim editing solution, ClaimStaker, covers the entire continuum of care, verifying claim data from the payer’s perspective and allowing for corrections prior to filing.
Check out our Denial Impact Assessment Calculator to see what your denials really cost your practice or contact us today for a free personalized Claims Assessment. See why ClaimStaker does more than clear claims. It gets claims paid.
We work hard to update our blog to keep you up-to-date on what’s happening in the field of medical billing software. If you have a topic you would like to see discussed, please contact us.
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