We are in an era of complex healthcare billing that can cost providers lost revenue due to lack of knowledge and proper training. Without these much needed tools, providers are faced with significant loss of revenue for their company. The good news is many of these mistakes are avoidable with proper checks and balances in place. Noted below are a few fundamental areas to pay special attention…
VERIFICATION OF BENEFITS
Accurate, upfront verification validation is a crucial step to avoid any future denials and loss of revenue before services have been rendered. Proper training and knowledge of the most vital questions to ask when validating covered services on insurance policy plans is the first necessary component (i.e., does the member have Out-Of-Network benefits or does the member plan include behavioral health benefits, etc.).
Keep in mind that you rely on the representatives from the carriers to provide precise and accurate data. Furthermore, unless you have the knowledge to identify inaccurate information being provided, the chance of you receiving invalid information at times may be significant.
It is also just as important to begin to have familiarity with the most common payers that you accept so that you may be able to have a knowledge base of the reimbursement pattern.
Another vital component in this industry is the utilization review process; which encompasses obtaining authorization for proposed dates of service. This is a stringent, meticulous process that compares requests for medical services to actual treatment guidelines set by various carriers. This process also sets the tone for the recommended direction of treatment. Obtaining authorization will essentially ensure that the services are deemed medically necessary and are in fact payable, which will also minimize loss in revenue. As a result, clinical documentation must be accurate and important information must be documented accurately.
BILLING & COLLECTIONS
Submitting claims with inappropriate coding is another major pitfall that providers are faced with. It is essential to have staff experienced with coding knowledge when billing to carriers to avoid upfront denials or decrease in reimbursement. Researching each carrier’s requirements will also help to assist in claims submission, but be mindful that their requirements can change frequently, so it is important to stay abreast of the changes when applied.
The most common pitfall is having inexperienced collectors that do not have a strong background in the area of specialty. It is imperative to have a team with the specialty skillset to handle claim denials and appeals in a timely fashion for reconsideration so that monies will not be left uncollected.
With all being said, it is crucial to have a strong internal and/or external team with the knowledge of handling all aspects of your revenue cycle management needs to ensure maximum reimbursement for ongoing growth.
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For facilities and healthcare providers to ensure that their claims are paid and processed accurately, they must first understand the intricacies of claims management and how inaccuracies affect not only reimbursement but the entire course of treatment. One of the key factors that affects reimbursement tremendously is documentation--which focuses on capturing and maintaining accurate and concise information.
As mentioned in previous articles, this industry is continuously changing; exorbitant requests for need-backs (used to authenticate medical necessity), denials for incorrect procedure and revenue codes, authorization requirement, nuances with various carriers, just to say the least. Consequently, documentation is a crucial aspect in this industry. It serves as the structural back-bone, which sets the overall tone of treatment. It influences the Utilization Review process, by determining the number of days’ treatment will be deemed billable or rather authorized dates of service. Billing and Collections; this process impacts coding and eliminates potential threats such as, aging and non-payment of claims. It also enhances the Clean Claims process by allowing the provider to follow coding procedures and guidelines.
If it was not documented, it simply was not done! Although it is understandable that physicians and clinicians are extremely busy and the needs of the patients are first and foremost, they must capture what they have done in order to be compensated for their services and the various levels of care.
Accurate documentation eliminates issues like: negligence, inaccurate diagnosis, as well as future inaccuracies that may potentially affect billing and collections and/or recoupment of funds, as mentioned above. It aids as a written explanation as to why a particular route was taken versus another mode of treatment and serves as a legal document that verifies the care provided. Accurate documentation helps in connecting the dots, painting the picture and/or telling the overall story. This process fundamentally validates the care/services rendered to the patient. Documentation is required to capture pertinent facts, findings, observation, history (i.e., past and present illnesses), assessments, examinations, course of treatment, and allows the provider to measure outcomes. Correct documentation practices have been identified as the driving force behind the International Classification of Disease, Tenth Edition (ICD-10) success, which aids in the reduction of misdiagnosis due to the criterion specificity that must be met. With the correct procedure in place, facilities and healthcare providers can achieve optimal growth across the spectrum-- increased reimbursement, meet reporting requirements and guidelines, reduce denials, and last but not least, reflect the level of care provided. In essence, documenting accurately impacts coding and reduces errors associated with claims processing.
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