One of the single most essential factors to maximize medical out-of-network claim reimbursement is accurate medical billing and coding. Even the slightest mistake can result in a delay or denial of a claim as payor automated processing systems are set up to deny claims for billing and coding errors. A successful coding and billing process should yield a nearly 100% claim acceptance rate. Practices also need to understand how a billing department/company has established its process for claim follow up and the timelines implemented for these processes. Absent a detailed process, claims can become ‘lost’ in the billing/collection cycle and time-out for reimbursement.
6 Billing, Coding and Practice Management Tips for Increasing Provider Revenue:
- Find root causes. Evaluate and correct the root cause of each claim rejection and denial and apply best practices to have the claim corrected and resubmitted within 24 hours, if feasible. A rejected claim has not been established as a timely filed claim and if not quickly resubmitted with necessary corrections, could time out as a timely filed claim.
- Employ a thorough patient eligibility and verification of benefits process. Setting up the claim to pay correctly begins with a detailed verification of benefits process and helps to avoid any errors in the collection of patients’ co-payment amounts. Practices should be extra vigilant in making sure patients are not being overcharged, particularly now as out-of-network claims will sometimes process according to a state-specific or federal surprise billing law.
- Know the Codes. Every specialty or surgical practice has reoccurring medical codes that are routinely used for commonly administered procedures. Knowing how to apply the proper modifier and any multiple procedure reductions (MPR) is equally as important to ensure the claim processes in a timely manner. The billing team and practice administrators should be well versed in the proper use of these codes/modifiers, ensure that operative reports support the codes being billed and should have a mechanism in place to track payment data by each CPT code and carrier. Under the No Surprises Act, this information is increasingly more important for pursuing and resolving disputed payment amounts between providers and payors.
- Adapt Coding Requirements Accordingly. For many surgical specialists, especially those performing advanced procedures, coding can be challenging as “recognized” coding may vary by insurance companies. As an example, certain procedures allow for an assistant surgeon while other similar procedures may not. Requirements for authorization for certain codes can also be dictated specifically by the policy or health benefit.
- Maintain accurate documentation. For pre-service authorizations and any assertions made by the payor pertaining to how the claim will be paid (ie UCR; multiple of Medicare, etc.), copious notes should be captured and recorded, as permitted by applicable law.
- Appeal under-reimbursed or denied claims. Any facts documented can and should be used to consistently and persistently to appeal denied and underpaid claims. Dedicated resources should be allocated within a practice (or outsourced to specialists) to implement a rigorous and effective appeal process. For claims not subject to a state-specific or federal surprise billing laws, payors generally allow 180 days to file an initial claim payment dispute, but time periods can vary by payor and type of plan. Also, It is important to note that all claims should not be treated equal and each claim should be evaluated by applying a specific methodology for determining the True Maximum Value of a Claim.
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Maximizing practice revenue begins with preservice, coding and billing. As the healthcare reimbursement landscape evolves, new regulations are enacted, and payor tactics to minimize payments persist, practices need a strong bench with deep knowledge of the out-of-network revenue cycle management and a clear understanding of the factors that impact revenue throughout the process.
Moreover, for certain underpaid or denied claims where payment is still disputed after the billing appeal process, the quest for payment should continue as warranted. Howard Healthcare Group and its affiliate Cohen Howard, LLP are collectively the only market solution capable of handling out-of-network provider claims from start to finish.
Having billing, coding, insurance, regulatory and legal expertise leveraged, and services managed across the RCM and beyond, provides a solution that clients are seeking. With our service solutions, clients are saving countless hours and resources handling business administration and revenue management functions. Instead, they are focusing their time on patient care while our team provides the deep bench necessary to maximize revenue for their out-of-network practices. Call us today for a free consultation on how we can help your practice maximize revenue.