A recent survey of U.S. healthcare organizations highlighted declining reimbursements as a top industry challenge. The COVID-19 pandemic changed payer billing guidelines, and reimbursement policies made receiving accurate reimbursement tougher. Reimbursement complications often lead to documentation and coding inaccuracies leading to increased claim denials.
The healthcare reimbursement process requires complicated steps and, at each turn, the risk of delay remains. Revenue Cycle Management (RCM) for practice management is difficult as the client pays after the services are delivered.
In the worst case, if the patient doesn’t have active insurance or delivered services are not covered, providers have to write off that amount. A few tips for making your Stronger RCM Team.
Tips of Making a Stronger RCM Team in 2022
Eligibility and Benefits Verification
The most important step in the Revenue Cycle Management Process is not submitting a clean claim, it’s eligibility verification and prior authorization for planned patient visits. Unfortunately, most practices, avoid doing eligibility and benefits verification, maybe due to lack of time or lack of skilled resources.
According to a recent survey report, nearly 80 percent of providers check patient eligibility, but only about 25 percent reverify the same patient for subsequent visits. If there is a change in the patient’s coverage and insurance information is not amended, stay prepared for a claim denial.
It is good practice to take a copy of the patient’s insurance card every time they visit, even if the patient says their insurance has not changed. Check that information against what you have in your practice management system before submitting a claim.
Accurate Patient Demographics and Insurance Information
Your billing must start work as soon as the patient makes an appointment. Start collecting data like patient demographics and insurance information and register the patient in the internal system or billing software. In the case of an established patient, check for any changes in patient or insurance information.
The patient might have updated their address or might added another insurance. Collecting accurate patient demographics and insurance information makes the foundation of billing and collections for any practice. Claim with incorrect information will lead to rejection or denial.
When denials happen, your team must spend time reworking and resubmitting the claim. If the information is not corrected, you could face even bigger reimbursement headaches down the road.
When it comes to billing hygiene, it’s best to submit a near-perfect claim the first time. You don’t want your staff wasting precious hours reworking claims that will only delay your reimbursement process.
Monitor Your Key Metrics
If you don’t have insight into your denial frequency, how can you expect to identify and correct the cause of poor reimbursement rates? Without intelligent revenue cycle solutions, actionable data, and a dedicated team to analyze your revenue analytics, you won’t have any idea as to why you’re not getting paid for services rendered.
Understanding what is driving revenue and duplicating successful billing and collection practices will lead to a stronger balance sheet every time. Use business analytics to set goals, monitor performance, and make informed decisions about your front and back-end workers.
Negotiate Your Contracts
Negotiating or renegotiating a payor contract is one of the best ways to improve your reimbursement rates. For example, a preferred provider agreement with the payor can give you more access to patients, especially when you agree to the payor’s payment terms, prior to providing services.
Patients will typically choose to be seen by an in-network provider since reimbursement rates are baked into the contract. However, out-of-network reimbursement can get complicated, as many insurance plans use Medicare fees as a basis for reimbursing services from out-of-network providers.
Avoid Trying to do it all
Medical billing and coding are challenging, it’s not merely submitting claims and receiving reimbursements, it’s more complicated than that. Try to avoid doing medical billing and coding all by yourselves. Most providers code and bill for the patient visits but that could lead to loss of reimbursements and could attract external payor audit.
When providers code, they use a set of procedure codes and use them again and again without understanding the basic coding guidelines. They also use few modifiers, as it might yield more reimbursement for the service. This can create serious trouble for your practice as the payor might see it as malpractice.
When providers think about outsourcing, they feel they have to give access to all information to manage billing and coding, but that’s not true. If you need assistance in a specific billing function for your practice, you can outsource only that function also.
If you don’t have qualified personnel to handle benefits verification or prior authorization requests, you can simply outsource that function only, the rest of the billing can be done by your Stronger RCM team only. The same is also applicable for denial management, old AR collections, medical coding, and many other billing functions.
Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services. If you need assistance in complete billing and coding or just a few functions, we have customized billing solutions for you. To know more about our billing and coding services, contact us at info@medicalbillersandcoders.com/ 888-357-3226
FAQs
1. Why is eligibility and benefits verification crucial in RCM?
Eligibility verification ensures that the patient’s insurance is active and covers the planned services, preventing claim denials and payment delays. Regular verification avoids surprises at the time of service.
2. How can accurate patient demographics impact revenue cycle management?
Accurate patient demographics and insurance details form the foundation of correct billing. Incorrect information leads to claim rejections, resubmissions, and delayed reimbursements, ultimately affecting cash flow.
3. What key metrics should be monitored in RCM?
Tracking key metrics, like denial rates and reimbursement cycles, helps identify areas for improvement. Analyzing data allows for more informed decisions and better billing practices to boost revenue.
4. How can negotiating payor contracts improve reimbursement rates?
Negotiating favorable payor contracts can secure better rates and improve access to patients. In-network agreements offer more predictable reimbursement, whereas out-of-network rates may require renegotiation.
5. Why should medical practices consider outsourcing billing functions?
Outsourcing specific billing functions, such as benefits verification or denial management, ensures accuracy and compliance. It allows practices to focus on patient care while experts handle complex billing tasks.
