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.
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 ]
There are five things to consider as you reopen your medical office: Reevaluate your budget; Get your staff’s buy-in; How to actively bring patients back into the office; Continuing to use Telemedicine and other online tools, and be flexible.
As the curve flattens and restrictions around the country loosen up, medical practices are slowly reopening their doors for non-essential services. But reopening doesn’t mean business will resume as usual. Every industry is making changes as we navigate a “new normal.”
Many of those changes center on social distancing guidelines, but there are other matters to consider as well. Here are some details about the strategies to keep in mind as you reopen.
Reevaluate Your Budget
Government restrictions may be lifting, but medical practices are not going to bounce back immediately. Any financial goals you had in place for 2020 likely won’t be met this year.
Some budgetary adjustments will be necessary. Here are just a few ideas:
Check in with vendors, landlords, and creditors to discuss any accommodations they may have for cash-flow disruptions
Consider delaying payment of bonuses and other discretionary payments
Seek aid from government economic relief packages and loans for small businesses and front-line workers. Stay informed on what your options are, as changes are ongoing.
This goes without saying, but make sure you’re up to date on patient billing and payments, too, including telemedicine visits. If you have patients who need extra time to pay their bills, EZClaim customers can set up a payment plan for them using BillFlash PlanPay.
Get Your Staff’s Buy-In
Before you start bringing patients back in, your entire medical staff needs to understand your new policies and be on board with enforcing them. They need to be reassured that their safety is a top priority, as well.
It’s been a difficult few months for front-line healthcare workers and will continue to be stressful in the months going forward. Do what you can to acknowledge their hard work and dedication.
Actively Bring Patients Back to the Office
Some people are eager to get out of their homes and into public spaces again, while others plan to shelter in place a while longer. Either way, your patients aren’t going to return in droves. Many are less comfortable going back to a doctor’s office, so be proactive about making your patients feel safe enough to return.
Americans have become experts on how viruses spread over the past few months, so anything you’re doing to clean and sanitize your office should be visible. Affixing physical distancing floor markers, procuring enough PPE for your staff, and installing hand sanitizer stations is a good start. Show your patients what you’re doing to protect them; simply telling them what you’re doing when they aren’t around won’t be enough.
As you communicate your new policies to patients, be aware that they may be feeling overwhelmed. Be transparent and connect with them on a personal level. Don’t be afraid to show your human side; otherwise, your office will be just another place with a long list of rules to follow.
Keep Using Telemedicine and Other Online Tools
The technology that got you through stay-at-home orders can continue to support you long term. Telehealth isn’t going away. Plus, patients will still want contactless payment options.
Evaluate what has worked over the last few months and incorporate them as part of your new normal.
For example, you may want to have a plan in place regarding which patients get priority with Telehealth. At-risk individuals will still need to stay home as much as possible, so make sure Telehealth will still be an option for them.
Another tool that has been valuable during the pandemic is contactless payments. COVID-19 has changed the way people are paying—for the good. They want the option to pay their bills online, or directly from their mobile devices. Some patients will even consider switching providers if another practice offers them online payment options their current provider doesn’t have.
Local outbreaks may still happen. Many households have lost income. Patients have different preferences and needs regarding where an encounter happens and how they pay.
Things are still changing by the week. As much as we all want a new, consistent normal, we need to be prepared to continue to make adjustments as needed. Ultimately, it is your patients and your practice’s financial health that will benefit from your ability to adjust to the times.
BillFlash, a fully integrated component and trusted partner of EZClaim, offers a variety of revenue cycle management services that have served EZClaim customers well for many years, as well as through the COVID-19 pandemic. For more information or to see a demo, contact BillFlash at 435-940-9123, email them at GetPaid@BillFlash.com, or visit their website at BillFlash.com.
Telemedicine was already growing in popularity prior to the onset of the Coronavirus pandemic. So, as the adoption rate increases, EZClaim clients may have questions about sending telemedicine charges and getting paid for Telehealth visits.
Telehealth challenges can range from issues with technology to getting paid. With Telehealth becoming the norm for many doctor-patient visits, it is important to have a thoughtful approach in place regarding collecting patient payments. To stay in business, you have to get paid for the work you are doing. So, establishing a process for Telehealth consultations is vital to your business, and it should be a top priority to build a successful program from beginning to end.
The answers to the following questions will help set the baseline for how to collect patient payments for
What is my process for charging for copays?
How and when do I collect outstanding balances?
For example, if you collect payment before an in-person visit, you should collect payment before a Telehealth visit, too. There is no need to re-create your process completely. Just change what is needed to match your current in-office routine.
Sending Charges Before a Telehealth Visit
A simple way to send pre-visit charges to patients is to provide them with a link that takes them directly to the payment site. EZClaim’s medical billing solution is integrated with BillFlash LinkPay, which enables customers to provide payment for the upcoming visit. So, before the Telehealth session begins, the practice simply sends a link to their patient via an e-mail or text, making the appointment confirmation and the payment processing part of the check-in process. After the payment transaction is complete, it will immediately show up on the practice’s BillFlash report. LinkPay is designed to be easy to use and doesn’t require patients to remember a login or a chart number.
Here’s how EZClaim enables the process through BillFlash:
Prior to Telehealth visit, the patient is sent a link to pay through LinkPay, and another link to join the Telehealth call
The patient pays the required amount through LinkPay, which is immediately confirmed and processed
The patient joins the Telehealth session
Results and follow-up are completed electronically
Insurance billing is completed
The patient receives a paper statement or eBill notification for any remaining balance
The patient is directed to pay the remaining balance online at MyProviderLink.com
Automate What Can Be Automated
With so many changes taking place in healthcare, a great way to help protect the financial stability of your practice is to automate what can be automated. This saves your staff time and decreases your cost of doing business.
One way to do this is to set up automatic payment plans for patients, particularly for those who have been hit hard by the economic impact of COVID-19. A payment plan is a good way of keeping the revenue flowing in, and it shows your patients that you are compassionate and willing to help them through these unprecedented times.
BillFlash also securely stores payment information, so patients will not need to re-enter their information every time they pay a new bill.
As you continue to adjust to Telehealth going forward, BillFlash can simplify patient billing and payments significantly and help getting paid for Telehealth visits.
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