Revenue Leakage in Medical Billing
‘Revenue leakage’ refers to situations where a healthcare provider doesn’t receive insurance reimbursement for delivered services. In such billing situations, accounts receivable remain unpaid for too long and eliminate the chances of payment recovery, even partially.
Healthcare practices cannot afford to ignore their revenue leakage as it’s directly affecting their ability to smoothly run day-to-day activities.
The good news is that providers can address many of the revenue leakage causes by identifying inefficiencies, improving their processes, and targeting improvement.
In this article, we shared 7 ways to reduce revenue leakage in medical billing, let’s discuss them in detail.
7 Ways to Reduce Revenue Leakage in Medical Billing
1. Quickly Submit Claims
Your billing team’s prime responsibility must be to submit insurance claims as soon as possible, ideally within 24 hours of the patient visit. Your billing team should be ready with all required details prior patient visit like patient demographics, insurance information, insurance coverage, patient responsibility, referral number, and prior authorization (if any).
Once your coding team provides procedure codes and modifiers, you can submit claims quickly. When you quickly submit insurance claims, it offers a lot of benefits like quick insurance response, correcting rejected claims, and reduced AR days.
Every insurance company has different timely filling limits starting with 3 months up to 12 months. Ideally, you should not wait for such timely filing limits as a claim may get rejected at any stage, and once it returns to your desk, half the time is gone.
Familiarize yourself with the best practices that ensure timely filing of claims like using billing software; filing fresh claims daily; daily checking of benefits verification (including prior authorization); and rework on rejected and denied claims.
2. Entering Correct Claim Details
Entering incorrect patient demographics and insurance information is the prime reason for claim rejections. Prime reasons for claim rejection include the incorrect date of birth, name or spelling, subscriber number, incorrect zip code, and subscriber information.
When the claim is rejected, it’s stuck in billing software and it does not reach the payer’s system until it’s been corrected. To reduce such rejections, you need to improve the patient registration process. Each and every patient’s details need to be crosschecked to verify their correctness. There are several ways to crosscheck these details.
You can use the provider portal, or use clearinghouse services. Some billing software shares such benefits reports with a single click, or you can directly call the insurance rep. These activities will help to bring claim rejections as low as 5 percent while identifying prior authorization requirements.
3. Crosschecking Insurance Coverage
Using eligibility and benefits verification you can reduce your revenue leakage to a great extent. In the eligibility and benefits verification process, the billing team will check the patient’s eligibility for planned procedures along with the patient’s overall benefits.
If a patient doesn’t have active insurance coverage then you can communicate with the patient for alternate insurance. The eligibility and benefits verification process also helps to find out prior authorization requirements.
Eligibility and benefits verification provides you the assurance that you will get paid for the delivered services as the patient is having active coverage.
4. Reduce Coding Errors
Medical coding is the core of revenue cycle management. Medical coding can be challenging as coding guidelines get updated constantly, plus coding guidelines slightly change as per insurance company and state.
Frequent coding errors include using incorrect or deleted codes; missing modifiers or combination codes; lacking medical specialty-specific coding experience, and undercoding. Most practice owners make the mistake of doing medical coding all by themselves.
In such situations, they tend to use few procedure codes for all their patient visit. Such activities will not only attract compliance issues but also impact the practice’s revenue in long term. It’s a must condition to have a certified, experienced medical coder who has done coding for your medical specialty in your area.
Such a qualified coder will help you code accurately and will also use modifiers whenever applicable. You also need to invest in their training to ensure that they are updated with current coding guidelines.
5. Entering Accurate Diagnosis Codes
The diagnosis codes are important because it provide a common language for recording, reporting, and monitoring diseases. The diagnosis codes support the medical necessity for the service and tell the insurance companies why the service was performed.
It can be the source of denial if it doesn’t show the medical necessity for the service performed. The current version of diagnosis codes i.e., ICD-10 comes with the basic requirement of using diagnosis codes with the correct level of specificity.
You have to use accurate diagnosis codes as using codes from the right family is not enough, and might cause claim denial. To eliminate such claim denials, healthcare providers should share accurate diagnosis on time.
Your billing team can cross-verify the correctness of diagnosis codes as certain billing software and clearinghouse services also provide such suggestions.
6. Comprehensive Denial Management
Denial management is a strategic process that aims to resolve problems leading to medical claim denials. Denial management also sets up a process that mitigates the risk of future denials. Not working on denial causes is the major reason for revenue leakage for any healthcare practice.
According to a recent survey report, the average claim denial rate has increased by 23 percent compared to four years ago. For medical practices, this means unpaid services, resulting in lost or delayed revenues, hurting the financial health tremendously.
The comprehensive denial management process includes steps like identifying the denial cause; resolving denials; monitoring; and preventing the occurrence of the same denials. Your coders, billers, AR team, and physicians should work together to identify, resolve, monitor, and prevent claim denials.
7. Ensure Provider Credentialing
All your physicians must be medically credentialed to be reimbursed by insurance companies. Every insurance company wants you to get credentialed before you start interacting with the patients. The credentialing process validates that a physician meets standards for delivering clinical care.
The insurance company verifies the physician’s education, license, experience, certifications, affiliations, malpractice, any adverse clinical occurrences, and training. The insurance companies might delay or refuse payments to physicians who are not credentialed and enrolled with them.
Getting the documents completed on time ensures that the new nurse or physician you’ve employed can start offering services on the first day. Provider credentialing is not something to push off as the credentialing time frame differs by state due to changes in legislation and credentialing laws.
Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services. We are confident that the above-mentioned ways will certainly help to reduce revenue leakage for your practice.
But you need experienced and skilled billers and coders to execute such strategies reducing revenue leakage. Another challenge is to hire, retain and constantly train such billing team, involving a lot of investment.
You can hire our medical billing and coding services to eliminate your revenue leakage.
Our customized, cost-effective, and medical specialty-specific services ensure that you will earn more reimbursements while staying compliant with payer-specific and state-specific guidelines.
To know more about our overall revenue cycle services, email us at: info@medicalbillersandcoders.com or call us at: 888-357-3226.
FAQs
1. What is revenue leakage in medical billing, and how does it affect healthcare practices?
Revenue leakage occurs when healthcare providers fail to collect full reimbursement for services rendered, often due to billing errors, claim denials, or inefficiencies in the revenue cycle process. It directly impacts the financial health of a practice, leading to unpaid claims, reduced cash flow, and limited resources for day-to-day operations.
2. What are the common causes of revenue leakage in medical billing?
Some common causes of revenue leakage include:
- Delayed submission of claims
- Incorrect patient demographics or insurance details
- Coding errors
- Missed prior authorizations
- Inaccurate diagnosis codes
- Inefficient denial management processes
- Lack of provider credentialing
3. How can timely submission of claims help reduce revenue leakage?
Submitting claims quickly, ideally within 24 hours of a patient visit, ensures faster insurance responses and reduces the chances of claims being rejected or delayed. It allows more time for corrections and re-submissions if needed, ultimately improving cash flow and minimizing unpaid claims.
4. What role does proper coding play in preventing revenue leakage?
Accurate coding is crucial to avoiding claim rejections or denials. Medical coders must use correct procedure and diagnosis codes, apply appropriate modifiers, and stay updated with insurance-specific and state-specific coding guidelines. Errors in coding can lead to compliance issues, lost revenue, and potential patient harm.
5. How does provider credentialing impact revenue collection and reduce leakage?
Provider credentialing is a process where insurance companies verify a physician’s qualifications and credentials before allowing them to bill for services. If a physician is not properly credentialed, insurance companies may delay or refuse payment for services, causing significant revenue leakage. Ensuring all providers are credentialed before treating patients helps prevent this issue.
