Medical Billing and Revenue Cycle Management

  Prompt payment to healthcare providers for their services is crucial for a detailed discussion on managing macro costs, quality, and equity. Without it, addressing the issue of rising healthcare costs becomes challenging. Healthcare providers are well aware that getting paid is not an easy task. A quick search for revenue cycle management (RCM) reveals 16-step pie charts, highlighting the complexity of this $140 billion market in the United States, which employs 188,000 medical records specialists. Successfully managing revenue cycles, which involves capturing fair payment with minimal effort, is a specialized business function. The complexity and labor-intensive nature of RCM make it difficult for a typical healthcare practice to master. If you find yourself spending too much on RCM staff and processes or if your claims denial rate is higher than the industry average, outsourcing your medical billing may be a solution to your problems. By allowing experts to handle payment colle...

  The healthcare industry is constantly evolving, and with it, so are the processes and procedures that are involved in billing and coding. As we move towards a more digital and technology-driven world, it’s important for healthcare professionals to stay up-to-date with the latest trends and changes in the industry. In this blog post, we’ll explore the future of healthcare billing and coding and what you need to know to stay ahead of the game. Automation is the Future One of the biggest trends in healthcare billing and coding is the increasing use of automation. With the help of technology, healthcare providers can automate many of the manual processes involved in billing and coding, such as data entry and claim submissions. This not only saves time but also reduces the risk of errors and improves accuracy. In the future, we can expect to see even more automation in healthcare billing and coding. This includes the use of artificial intelligence (AI) and machine learning to analyze ...

  Revenue cycle technology comes in various forms, tailored to the specific needs of healthcare providers, yet these indispensable tools have become vital for ensuring seamless operations within the revenue cycle. The healthcare revenue cycle represents a vast and intricate operation that encompasses a range of activities, from patient registration and insurance verification to denials management and patient collections. To ensure smooth and efficient operations, healthcare provider organizations of all sizes have embraced revenue cycle management technology. There exists a diverse array of technologies utilized by providers to streamline various aspects of the revenue cycle, often incorporating several of these tools as part of their management strategy. According to a recent survey of healthcare finance leaders, approximately 30 percent of organizations employ two or more vendors for automating their revenue cycle, while 38 percent rely on a single vendor for all automation steps...

  Medical billing outsourcing services can significantly help healthcare providers improve their revenue collection and reduce claim denials. Outsourcing medical billing to specialized companies or billing agencies offers several advantages that can positively impact the revenue cycle management of healthcare organizations. Here's how outsourcing can be beneficial: Expertise and Experience: Medical billing outsourcing services employ experienced billing professionals who are well-versed in the complexities of medical coding, billing regulations, and payer requirements. Their expertise can lead to accurate and optimized billing practices, resulting in increased revenue collection. Reduced Claim Denials: Outsourcing companies have robust processes in place to minimize claim denials. They perform thorough checks to ensure that claims are complete, accurate, and compliant with insurance company guidelines. This reduces the likelihood of denials and rejections. Faster Claim Pro...

  In 2019, the Office of the Inspector General (OIG) for the U.S. Department of Health and Human Services (HHS) found that one in every eight prior authorization requests was denied by Medicaid managed care organizations. Dive Brief: A recent report by the HHS’ Office of the Inspector General suggests that due to high rates of  prior authorization denials  and limited state oversight, certain beneficiaries of Medicaid managed care may face difficulties accessing essential medical care. In the study, Managed Care Organizations (MCOs) were found to have denied one out of every eight prior authorization requests in 2019, with some organizations showing denial rates surpassing 25%. This data reflects the most recent available information. The OIG’s report further highlights that many state Medicaid agencies did not regularly monitor whether prior authorization denials were appropriate, which resulted in the unnoticed prevalence of high denial rates. Additionally, the appeals ...

  Medical billing can be a complicated landscape with costly and alarming risks. From minor transcription errors to major coding misunderstandings, inaccuracies in this field may lead to lost income or legal complications for your healthcare organization. While some medical billing problems stem from simple oversights, others result from systemic challenges. However, all of these issues have solutions if you know where to find them. Get ready to explore the most common obstacles to medical billing accuracy and learn practical strategies to overcome them. Resolving 10 Common Challenges in Medical Billing: Although medicine presents many challenges, with a solid plan, they can be overcome. Let’s take a deep dive into identifying and resolving the most frequent obstacles in  medical billing practices . 1. Inaccurate Patient Details The significance of accurate patient information in medical billing cannot be overstated. Even minor mistakes, such as misspelled names or incorrect b...

  The OPPS proposal lacked any mention of several prominent issues that industry leaders have eagerly awaited reforms on. Yesterday, federal officials introduced two sets of proposed rules, which included possible revisions to the Medicare Physician Fee Schedule (PFS) and Outpatient Prospective Payment System (OPPS) for the 2024 calendar year. Within the PFS proposed rule alone, the Centers for Medicare & Medicaid Services (CMS) announcement emphasized several key points. These included rate updates, efforts to promote health equity, and initiatives to broaden access to essential medical services, including behavioral healthcare and specific oral health services. Additionally, the PFS proposed rule aligned with the Biden-Harris Administration’s “Cancer Moonshot” mission, aimed at accelerating the battle against cancer. In a statement, CMS Administrator Chiquita Brooks-LaSure expressed our mission at CMS, which revolves around increasing healthcare accessibility and providing me...

  Here are five common mistakes you should avoid to prevent revenue loss 1. Inappropriate medical Coding: Frequently,  medical coding for evaluation/management services   tends to be excessively aggressive or overly passive, leading to coding errors. These mistakes are primarily due to the misinterpretation of E/M coding guidelines and the fast-paced nature of the clinical environment. Aggressive coding arises when there is insufficient documentation to support the provided services, while passive coding fails to consider the full scope of the work performed. 2) Missing E/M Codes: Many times, this occurs due to incomplete charting, often caused by distractions experienced by the healthcare providers. When charts lack proper follow-up, it frequently leads to delayed medical claim submissions or even unbilled claims. 3. Inaccurate  Capturing of status: The uncertainty regarding a patient’s status as new or established, a determination typically made at the front desk,...

  As healthcare providers, ensuring that your accounts receivable (A/R) is properly managed is crucial to the financial health of your practice. However, managing healthcare A/R can be a daunting task, especially when it comes to follow-up on denied claims. In this ultimate guide, we’ll provide you with best practices to effectively manage your healthcare A/R and turn denials into dollars. Understanding Healthcare A/R Accounts receivable in healthcare refers to the amount of money owed to a healthcare provider for services rendered but not yet paid by the patient or insurance company. Managing healthcare A/R involves tracking, billing, and collecting payments for services provided. Healthcare A/R management is essential to the financial success of any practice, as it directly impacts cash flow and revenue. Common Causes of Denied Claims Denied claims are one of the biggest challenges in healthcare A/R management. Understanding the most common causes of denied claims can help you pr...

  The effectiveness of revenue cycle management relies on a proactive approach that integrates key performance indicators (KPIs), benchmarking, and frequent performance evaluations. The revenue cycle plays a crucial role in the long-term financial sustainability of healthcare practices as it impacts all areas of their operations. To enhance revenue and streamline processes, healthcare practices are adopting a proactive revenue cycle strategy that involves optimizing each stage of the cycle and addressing vulnerabilities before they become problems. By embracing a proactive revenue strategy, healthcare practices can improve their revenue cycle and maintain a cohesive approach to people, processes, and technology. However, to successfully execute a proactive revenue cycle strategy, practices must establish clear goals, understand industry benchmarks, and conduct regular performance reviews. Define Goals and Establish KPIs When developing a proactive revenue cycle strategy, start by d...

  On July 13, 2023, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule seeking public feedback on proposed policy changes for Medicare payments under the Physician Fee Schedule (PFS) and other Medicare Part B issues. These changes are set to take effect on or after January 1, 2024. The proposed rule for CY 2024 PFS is part of a larger effort by the current administration to create a more equitable healthcare system that improves access to care, quality, affordability, and innovation. Background on the Physician Fee Schedule Medicare has used the Physician Fee Schedule (PFS) to pay for physicians’ and other billing professionals’ services since 1992. These services are provided in a variety of settings, including hospitals, physician offices, skilled nursing facilities, hospices, and outpatient dialysis facilities. Medicare makes payments to physicians and other professionals at a single rate for most services furnished in a physician’s office. However, ...

 The potential benefits of outsourcing medical billing and coding services to a medical coding company for reducing billing errors and claim denials include: Access to experienced and specialized expertise . Medical billing and coding companies have teams of experienced medical billers and coders who are up-to-date on the latest coding and billing regulations. This can help to ensure that claims are coded correctly and submitted accurately, which can reduce the chances of errors and denials. Improved efficiency and productivity. Medical Billing companies have the resources and infrastructure to process claims more efficiently than many in-house billing departments. This can free up your staff to focus on other tasks, such as patient care. Reduced costs. Outsourcing can help to reduce the overall cost of medical billing and coding. This is because medical coding companies typically charge a flat fee per claim, rather than hourly wages. This can save you money on salaries, b...

  The 2024 Medicare Physician Fee Schedule proposal includes a reduction of 3.4% to the conversion factor that determines Medicare payment rates. This reduction will widen the gap between practice expenses and reimbursement. If the proposal is approved, the new conversion rate will be $32.7476. Here are some other key highlights of the CMS proposal: The proposed changes to Medicare telehealth services would have several effects, including: Reimbursement for telehealth services provided to patients in their homes would be at the non-facility rate, which is typically higher. Telehealth services listed on the  Medicare Telehealth Services  List would continue to be covered and reimbursed through 2024. Direct supervision by a practitioner through real-time telecommunications would still be allowed through 2024. Split or shared E/M visits could be billed based on history, exam, or medical decision-making, or alternatively, time, until the end of 2024. https://www.allzonems.com...

  Based on FAIR Health’s Monthly Telehealth Regional Tracker, the national decline in private insurance telehealth claims reached 5.4% in April, comprising 5.3% of all medical claims. This reduction can be observed across all four U.S. census regions: the Midwest (4.7%), Northeast (6.3%), South (6.8%), and West (6.4%). On average, patient visits lasted between 20 and 29 minutes, with a median charge of $167.77 and a median allowed amount of $89.70.According to the data collected from privately insured populations, including Medicare Advantage and excluding Medicare fee-for-service and Medicaid, audio-only telehealth experienced a decline in both rural and urban areas nationwide and in every region except the West. Interestingly, in the West, it decreased in rural areas but saw an increase in urban areas. Across the board, mental health conditions remained the most prevalent telehealth diagnosis, maintaining their top-ranking position nationally and in every region. In March, they a...

Collaboration among a diverse team that blends clinical expertise and technical proficiency is essential in today’s dynamic healthcare environment to overcome administrative and diagnostic challenges. This multidisciplinary approach facilitates the creation of healthcare technology solutions that benefit all stakeholders, including payers, providers, and patients. By adopting a more personalized approach, treatment outcomes can be optimized while empowering payers to authorize clinically-appropriate care for all members. These platforms revolutionize the healthcare landscape by harnessing the power of technology, paving the way for a future where everyone can receive the highest standard of care tailored to their specific needs. The Transformative Role of Clinical Technology in Modern Healthcare Advanced algorithms and clinical information analytics have made clinical technology a potent tool for navigating complexities that are beyond human comprehension. Technology-driven platforms t...

  Telemedicine or telehealth, which refers to providing care via electronic communication when patients and providers are in separate locations, has been available for decades. However, the COVID-19 pandemic has accelerated the adoption of telehealth due to the urgent need to deliver care in new ways. Before the pandemic, telehealth faced challenges such as limited reimbursement, cross-border licensure requirements, and access to technology. The pandemic prompted increased flexibility in reimbursement and explosive growth in telehealth services. Eventually, these terms may become commonplace in healthcare and simply be referred to as “healthcare.” However, for now, compliance considerations must be taken into account as telehealth is subject to various state and federal healthcare regulations. 1. Ensure the privacy and security of data remains intact During the COVID-19 pandemic, the U.S. Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) temporarily waive...

  The President administration has announced its intention to restrict the sale of “junk” insurance policies, including short-term plans that may not provide adequate coverage for individuals who are in-between jobs and require temporary health care coverage. These policies have been known to deny basic coverage to policyholders. On Friday, President announced a set of fresh measures aimed at reducing health care expenses. These include taking action against fraudulent insurance policies, offering guidance to prevent sudden medical bills, and reducing medical debt associated with credit cards. These initiatives complement previous efforts to limit health care costs, including the introduction of a cap on out-of-pocket expenses as part of the Inflation Reduction Act last year. The Department of Health and Human Services has estimated that around 18.7 million Medicare beneficiaries and older adults will save approximately $400 per year on prescription drug costs by 2025 as a result o...

  Review the changes to ensure that ICD-10-CM codes are reported accurately On July 5th, The National Center for Health Statistics released the 2024 update to the ICD-10-CM Official Guidelines for Coding and Reporting. It is recommended that medical coders and auditors review these guidelines on an annual basis to ensure accurate reporting of patient conditions and encounters. The updated guidelines, along with the ICD-10-CM code set, will take effect on October 1st, making it an ideal time to review the changes. Chapter Specific Changes to Guidelines The majority of changes made to the diagnosis coding guidelines for fiscal year (FY) 2024 are specific to certain chapters. These changes consist mainly of minor narrative corrections and the addition of a small number of new diagnosis codes. However, there are a few notable significant additions as well. note: any narrative changes to the diagnosis coding guidelines are indicated in bold typeface, any text that has been moved is unde...

    In the ever-evolving field of healthcare, accurate diagnosis and effective treatment depend on a universal coding system that provides a common language for medical professionals worldwide. The International Classification of Diseases (ICD) serves as the backbone of this system, and with the recent transition to ICD-11, a new era of coding has begun. In this article, we will explore the significant changes introduced by ICD-11 codes and shed light on what you need to know about this updated classification. The Evolution of the ICD The ICD is a comprehensive classification system that enables the uniform recording, reporting, and analysis of health conditions and their related factors. It plays a vital role in clinical decision-making, healthcare planning, research, and policy development. The ICD has been regularly updated to keep pace with advancements in medical knowledge, technology, and terminology. The latest revision, ICD-11, represents a significant milestone in the...

  Part of the reason for the decrease is attributed to a permanent adjustment in behavior assumptions. The 2024 Home Health Prospective Payment System Rate Update proposed rule released on June 30 revealed that Home Health Agencies will experience a 2.2% payment decrease in 2024 compared to 2023, partly due to a permanent behavior assumption adjustment. CMS issued a 2.7% payment increase for 2024, but this was offset by a 5.1% decrease in permanent behavior assumption adjustment and another 0.2% decrease due to the fixed-dollar loss ratio, as per the statute. CMS found that Medicare paid more under the new system than it would have under the old system, using updated 2022 claims and the methodology finalized in the 2023 final rule. As a result, CMS is proposing an additional permanent adjustment percentage of -5.653% in 2024 to address the differences in aggregate expenditures. WHY THIS MATTERS The proposed rule suggests a permanent, prospective adjustment to the CY 2024 home healt...