Common Medical Billing Mistakes and Healthcare RCM Solutions to Improve Revenue and Collections
Providing medical care with the highest satisfaction of patients is the ultimate goal for a healthcare business; undoubtedly, reliable medical billing service plays a vital role in delivering quality care and avoiding common medical billing mistakes. Whether you have a physical therapy practice, internal medicine or family practice, or any other specialty, the most important thing is to have smooth RCM operations to ensure constant cash flow. Medical billing and denial management problems can slow you down, increasing pressure on your finances. Utilizing medical billing management companies decreases the possibility of encountering billing complications and effectively improves healthcare business offices and clinical workflow management efficiency. Medical Credentialing Service is the one fundamental service that medical billing companies offer to start things with new practices.
The fundamental problem in the healthcare business is collecting due balances from patients in a certain way it could improve the cash flow for healthcare entities. If you have an effective medical billing services company on board, you can automate the process of generating and tracking the due balances, sending reminders to the patient with a specific interval, and allowing the patients to pay the bills with ease of access. Due to the complex healthcare system, there are challenges, but a good RCM workflow can automate the payment collection process to achieve higher results.
The Seven Most Common Issues / Problems with In-House Medical Billing at Physician’s Offices and How to Fix Them:
The following is a list of seven common problems if you have an in-house medical billing department or planning to have one, along with the remedies to those problems!
1. An Absence of Necessary Information
It is common for medical billers at physicians’ offices to make the mistake of leaving important information off of a claim, such as patient’s demographics information, insurance information, and in case of auto accident claim accident/injury date and other worker compensation details. Even if the patient’s insurance has the benefits coverage and the claim can be processed towards reimbursement in the first attempt, not having enough information will result in more claim denials.
During the intake process, please check for missing or blank information. It is your best opportunity to spot omissions before they lead to a time-consuming procedure of denial and resubmission or contacting the patient for missing information.
2. Incorrect Identification Information Regarding the Patient
When entering patient information into your medical billing software or an EHR Software, you risk making claims reimbursement more difficult even if there are minor errors. It is common amongst clinicians that they face claims denials from insurance companies due to minor errors. If the denial management is not adequately set up, that can cause problems in getting the claims paid. Such mistakes as misspelling a patient’s name or changing their birth date can result in considerable losses in revenue and collection.
There are two approaches to taking care of this problem. The patient information should be taken by the intake department if that’s working separately from Medical Billing Staff working in-house. This allows them not to multi-task and focus on taking the most accurate information. The second step is to find a medical billing company that can help to perform a pre-submission claim audit to ensure that claims are going with maximum accuracy. Medical Billing Companies have software that can check the eligibility before generating the claims EDI files for submission. Their internal auditing process ensures that a validated clean claim is submitted to ensure timely reimbursement.
Imagine that before patients come in for their first evaluation visit, you ask them to enter their information, validate it with you, and later call them back, asking to verify the information as you have received a denial on the claim submitted to the insurance company. Healthcare providers must have a streamlined workflow to take the most accurate info from patients, which could result in faster reimbursement from insurance and patients.
3. Healthcare Claim Coding and Clinical Workflow Issues
Incorrect medical claims coding is one of the most common mistakes made by healthcare professionals and one of the most time-consuming mistakes. Claims may be incorrectly coded for a variety of reasons, including the following:
- Utilization of expired Codes (CPT Codes and ICD-10 Diagnosis Codes)
- Bundled Services Billed Without Modifier
- Ignoring the Mutually Exclusive Edits (PTP Coding Edits)
- Overcharging and Under Billing of Services
- Incompatible CPT or ICD-10 Diagnosis Codes
- Expired/Absolute CPT and ICD-10 DX Codes
The solution to these problems is to have a Top-Rated Medical Billing Company standing by your side that has all the automation and procedures in place to ensure that they don’t drop any ball while validating the claim and preparing it for submission the final claim. Most Medical Billing Companies ensure that the CPT/ICD-10 Diagnosis Codes are up to date and make consistency between the services provided. It helps healthcare professionals to maintain consistent healthcare coding standards. When you use Medical Billing Software or an EHR – Electronic Health Record, you can incorporate only the codes that are compatible with your specialty and the services you have selected to provide. This reduces human error and alerts the clinical staff when a selected service doesn’t qualify to be compatible with healthcare provider settings. The result is spending less time on Charting in EHR Software and focusing more on delivering quality care to your patients who needed the most.
4. Claims Submission More than Once
When dealing with different healthcare providers’ staff members, we have observed that they tend to resubmit the claim more than once, thinking that it will help to get the claim paid without focusing on why it has never been paid in the first place. There could be other mistakes leading to this one that might include patient billing as an option, as they might see that patient’s coverage has some issues. Unnecessary claim submission to insurance companies will result in multiple denials. Later, when in-house medical billing teams start to follow up, it becomes more challenging to determine which claim is the original and which should be rectified. If patient billing is also involved, which will reduce patient satisfaction, and healthcare offices end up getting bad reviews, this can ruin the whole healthcare business reputation.
The answer to such a problem lies in the automation of the medical billing process that is being handled by most healthcare RCM Solutions Providers to ensure that healthcare professionals get paid for the services provided. Medical Billing Companies have a process to detect duplicate submissions, and even rules can be enabled in EHR and RCM Software to ensure if anyone attempts to create a second charge for the same services and treatments, that must generate an alert. Medical Billing Staff training can also help to reduce such mistakes when managing an in-house medical billing team. Continuous training of the medical billing team is essential to keep up with the healthcare industry changes.
5. Insufficient Documentation
To process claims and make payments, all healthcare providers, physicians, and clinical staff members must maintain electronic copies of medical documentation. If not using an EHR, they must maintain the paper trail. Even though CMS has encouraged healthcare providers to use the EHR and issued significant incentives in the last decade to help in the adoption of EHR, some providers still use paper charting and have not evolved their process to the EHR-centric medical documentation record system or EMR – Electronic Medical Record systems. If you do not maintain the medical documentation, that can cause problems such as when insurance decides to hold the claim requesting medical documentation or later they may reject if they do not receive the medical docs in a certain period. Healthcare providers may face other challenges, such as CMS audits the practice to ensure they comply with all HIPAA, HITECH, and other regulatory requirements. To meet all the healthcare standards, healthcare providers must ensure that they maintain sufficient medical documentation to prove the necessity of the claim and comply with all healthcare regulatory laws and requirements.
Your medical billing services staff enables you to spend more time charting and maintaining the healthcare laws so you can do your job accurately. The expert medical billers at medical billing companies focus submit a clean claim and getting you paid as quickly as possible.
6. Change in Patient Insurance Coverage Due to Change in Employment
Many factors can affect a patient’s insurance coverage, including a change in employment. If you do not have an EHR System that could track the patient’s employment history, you would not be able to find a clue why claims are not getting paid suddenly, whereas this was not the case before. In addition, caps may be placed on the total number of visits or treatments paid by the employer-sponsored healthcare plan during their employment period. If these caps are exceeded, the patient will be liable for covering the additional costs.
If the healthcare claim is sent to insurance and denied, which requires the patient to update the COB – Coordination of Benefits, you must inform the patient about it. If claims are still being submitted and resubmitted incorrectly, it could result in costly delays and make it more challenging to recover from the patient health plan. Since you can’t identify the new insurance carrier, you won’t be able to get the claim paid. At each visit, it is essential to confirm that the patient is covered by their insurance plan. The healthcare provider intake department is responsible for confirming the patient’s insurance coverage when scheduling the appointment while ensuring their benefits have not expired.
Outsourcing medical billing to a professional healthcare RCM company with well-rounded denial management services can help you identify such claims denials so you can coordinate with your patients to see if they have any other insurance that can cover the cost or if they are willing to pay the cost out of their pocket.
7. The lack of Either a Referral or Prior Authorization
Patients enrolled in specific medical plans must receive a healthcare service from their PCP or Primary Care Physician. If patients need to visit any other specialty healthcare professional or a specialist for further diagnosis and treatment, they must have prior approval from the patient’s insurance; that’s called Prior Authorization. It’s common for healthcare providers to refer patients to other healthcare specialties they do not deal with so the patients can get the appropriate services.
But if the prior authorization has not been obtained by the insurance company, meaning approval has not been taken by the patient’s healthcare carrier before providing the services, that can also result in denials, and in a few cases, you even can’t request a retroactive authorization that allows you to request the prior authorization in the back date for the services has already been provided. To prevent this problem, you will need to confirm with the patient or with the insurance plan which type of services are covered in their plan and if they have out-of-network benefits in case of an HMO plan or they have a PPO plan that allows the patient to visit the wide range of healthcare providers. You will also need to ensure that your staff is aware of the constraints and regulations, and restrictions imposed by the healthcare insurance carrier so they can comply. If the patient does not have a referral or prior authorization, you might try to obtain one through collaborative efforts with the patient’s insurance carrier before providing the services and even before submitting the claim.
Paying attention to detail is required to have an effective medical billing workflow at healthcare offices. Taking care of these mistakes can help you guarantee that your healthcare claims are accurate to get reimbursement and that your patients are receiving the appropriate level of care. Automating these medical billing processes can also help achieve constant cash flow for your practice and fewer denials from insurance companies.
All healthcare professionals understand the importance of outsourced medical billing services. At some point, they have to hire an Outsourced Medical Billing Company that is more innovative and effective. Since there is still a significant amount of risk involved and many things can go wrong, healthcare professionals can’t afford to face such a significant loss.
Outsourced Medical Billing Services Company
Managing a healthcare practice without having the right team standing by your side is much more difficult. If you have decided to have an in-house medical billing team, constant training and improvement of the Healthcare RCM Workflow are essential. Your best, in this case, can be to hire a Professional Medical Billing Company and outsource all of your Revenue Cycle Management related tasks to the Outsourced Healthcare RCM Company. This will allow you to focus on your business workflow and make an improvement every next day.
You would like to Outsource Medical Billing Services? Contact Us Today to schedule an appointment with our Healthcare RCM Consultant and see how iCareBilling can help you to improve your revenues and collections.
What is iCareBilling
iCareBilling LLC is an American Healthcare IT Company that provides Medical Billing, Practice Management, and RCM Services to independent healthcare practices, small, medium, and large-sized medical groups, healthcare clinics, laboratories, telehealth practices, and hospitals throughout the United States.
