If you find an overpayment, don’t expect to keep it. That’s because physicians must report and repay Medicare overpayments within 60 days of identifying them, according to a final rule that took effect March 14, 2016. This includes overpayments identified within six years of when the overpayment is received.
Do not forget the top 6 tips (given below) that will help physicians identify what could constitute an overpayment and how they should report overpayments as they discover them.
When used appropriately, modifier -25 can enhance revenue for a physician practice. That’s because reporting this modifier allows physicians to bypass an Outpatient Code Editor (OCE) edit to receive additional payment. However, physicians must understand the rules regarding this modifier—and the documentation required to support it. No physician wants to discover after the fact—during an audit—that he or she must pay the money back.
Here are some facts about modifier -25 that can help physician practices maintain compliance.
It’s a fact: Without an effective—and efficient—revenue cycle, physician practices cannot weather the storm of ongoing reimbursement changes in today’s healthcare environment. ICD-10, for example, has forced practices to take a closer look at their overall revenue cycle efficiencies as well as specific documentation and coding practices. Other regulatory changes, such as the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APM), continue to drive process improvement. A solid revenue cycle is the one constant amidst ongoing—and oftentimes unpredictable—change.
To ensure financial survival, practices must examine their revenue cycle regularly, looking for gaps and vulnerabilities and then taking steps to improve processes. This article provides seven tips practices can use to improve their revenue cycles in 2016 and beyond.
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The ICD-10 transition has gone surprisingly well for many physician practices nationwide. However, the industry is bracing for what could be a flood of denials once payers begin to adjudicate claims. Monitoring certain key performance indicators (KPI) will be critical, says Deborah Grider, CCS-P CDIP CPC CPMA CPC-H CPC-P, healthcare consultant at KarenZupko & Associates. This article identifies three of the most important medical billing KPIs that every practice should monitor now and heading into 2016.
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In a high-compliance environment, outsourcing medical billing functions seems like a loss of control for some medical practices. In reality, outsourcing claims billing with the right provider enhances physician control over billing processes. Outsourcing has also been shown to increase profits, productivity, and patient satisfaction.
An obvious reason to outsource medical billing work is to reduce overhead costs for your small medical practice. Managing claims processes is a full-time job requiring at least one staff member, which means practices pay salaries for one or more people along with benefits and other associated expenses. In an outsourced environment, due to economies of scale, medical billing vendors are able to fold claims into existing resources and processes, providing the same functionality for a fraction of the cost.
A study of 5,000 physicians indicated 60 percent spent a total of one day a week on administrative functions. Paperwork encumbers small medical practices, reducing clinician's ability to treat patients. Outsourcing administrative tasks streamlines in-house processes and reduces tedious paperwork tasks.
Relying on medical coding services from expert vendors decreases loss of revenue associated with claim denials. Medical billing vendors keep up with constant changes in medical billing requirements, making it possible for them to include proper modifiers and other coding on all claims. Proper coding and claim submission automatically drives up cash flow for your medical office.
Even in a perfect billing environment, denials happen for a variety of reasons. In an office setting, a denial costs you money because you pay staff extra time to find errors and resubmit claims. Most medical billing vendors charge a percent of paid claims, so you don't pay extra for work on denied or error claims.
When billing is done in house, it often takes a secondary seat to other work. Medical office staff may divide time between claims billing and patient-centered duties such as reception, answering phones, and collecting information. That means claims could sit for days or weeks before being billed, and denials could take months to resolve.
When you outsource medical billing functions, the vendor's experts don't have to split their time. Instead, they can bill claims immediately and follow up with insurance claims in a timely manner, increasing the rate of cash flow for your practice.
Healthcare providers appreciate the benefits of specialization in clinical applications. General practitioners don't attempt to treat their patients' serious cardiology issues, and doctors wouldn't ask reception staff to run an x-ray machine. The same need for specialization expands to the administrative functions of a medical practice. Outsourcing claims billing and denial management to specialists ensures the work is done by experts who make it a point to stay current on electronic claims requirements, billing and coding rules, and specific changes within payer organizations.
By outsourcing medical billing work, you free in-house staff up to assist patients. Patients who are greeted, communicated with, and seen in a timely manner are more likely to return to a practice and refer others. Fast, accurate claims processing from an expert organization is another way to increase patient satisfaction.
Medical billing vendors provide reports and statuses that let you assess financial health for your medical practice. Creating the same level of visibility and reporting in-house can be expensive and take time away from other necessary functions. Being able to understand your financial status, including the amount and number of claims pending in various statuses, lets you make smart choices about expansion, purchases, or hiring in your office.
Contact RevenueXL today to find out more about medical billing services and schedule a demo to see how our software and services can help your practice increase productivity and profitability.
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According to RemitData, two of the top five claim denial reasons for 2013 were insurance-coverage related. Millions of claims were denied because eligibility had expired or the patient or service was not covered by the plan in question. Putting a solid insurance verification process in place can reduce these types of denials in your practice, making medical billing practices more efficient and raising your overall bottom line.
Insurance should be verified before clinical services are provided and should never be a task the medical billing staff handles on the back end. Follow these five steps to reduce the chance your billing team deals with constant eligibility-based denials.
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According to Department of Labor estimates, around 200 million healthcare claims are denied each year. The agency estimates one in seven submitted claims is denied, many times for technical errors such as missing information or coding issues. Combine claim denials, time-consuming appeals processes, and claims that never even make it out of the office, and your medical practice could be losing money at an alarming but unnoticed rate. Some common sense organization tips can overhaul your claims process, healing claims wounds and increasing revenue.
The very first steps in the patient onboarding process can set the tone for information and claims management for the patient's first office visit. Getting as much information up front as possible helps front office staff understand whether the office participates with the patient's insurance and lets clerical staff begin an electronic medical chart for the patient. Organize onboarding processes by training staff and using call scripts or templates to gather information.
When a patient calls to set an appointment, gather the following information:
Create an electronic health chart by entering the demographics so this information doesn't have to be entered the day the patient arrives. Provide the patient with instructions for their appointment, emphasizing that they should bring their insurance card. A copy of the insurance card is one of the best ways to ensure you have the right claims billing information.
Always inform the patient that known copayments will be due on the day of service. Collecting small copays in your office is more cost-effective than allowing them to fall into a billing process.
Almost all of the information involved in a phone onboarding process should be repeated when the patient arrives for an appointment. Even if the patient has seen the doctor before, verify the information you have in your system. Print out a patient information sheet that includes name, phone number, address, insurance information, and date of birth; ask the patient to sign off that all information remains accurate. According to National Government Services, some of the top claims denial reasons reflect missing or incorrect information on the claims form. Double or triple checking basic information with the patient reduces the chance of such denials.
Front office staff should also make a copy of the front and back of the patient's insurance card. When possible, immediately scan the card into the electronic record. Claims billers require the information to verify insurance ID numbers and send the claim to the right payer.
Clinical processes often seem removed from administrative functions such as claims billing, but every piece of your medical practice works together like the gears on a clock. Without a valid clinical assessment and proper documentation, claims will be denied. In fact, medical necessity denials are always among the top ten denial reasons in any survey or study.
Doctors and nurses help reduce financial loss due to medical necessity denials by inputting accurate, complete information in electronic medical records. Software designed for specific practice types may even prompt clinical staff to answer the exact questions that are required in certain certifications of medical necessity on claims. Using such templates in the record provides an organized way for physicians to communicate answers to claims staff. Detailed, easy-to-access health records also provide billing staff with documentation for appeals when unavoidable medical necessity denials occur.
Medical offices with strong revenue have organized claims filing processes. In addition to using electronic health records, double checking insurance information, and ensuring all claims are complete, back-end medical office staff must stay up to date with HIPAA billing requirements. Many billing software vendors do the work to remain compliant with federal, state, and insurance standards so your office can concentrate on adjudicating each claim.
Claims billers should also have processes to track each service, ensuring claims are billed in a timely manner. Once initial claims are billed, use software or manual systems to set follow up dates to check the status of claims. Claims that haven't been paid after 21 to 30 days should be researched and appeals or corrected claims filed. Once primary claims are paid, billers should immediately work on filing secondary claims or sending bills for patient out-of-pocket expenses.
For more information on how electronic medical records and claims software lets your office take advantage of a more organized billing process, contact RevenueXL today.
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Do you know where resources such as time and money are being used best in your medical practice and where they might be wasted? Chances are, even the most organized and efficient office isn't following every best practice when it comes to medical billing or electronic health records implementation. Learning from the mistakes of others, keeping up with trends in the industry, and understanding how regulatory compliance plays a role in every task can mean the difference between a profitable practice and one that struggles with cash flow.
On October 1, 2014, all health care providers will switch from ICD-9 coding to ICD-10 coding when they bill private insurance, Medicare and Medicaid . To understand how large this move is, there are only 20,000 ICD-9 codes while the number of codes in ICD-10 set is nearly 70,000.
Healthcare finance officials disagree on whether the new coding will increase or decrease initial denials. It is clear that when the October 2014 deadline comes, provider productivity will see an initial drop in due to denial of claims that will eventually drop off to similar levels existing today. However, denial management will become easier as the increased specificity of the ICD-10 classification system makes it easier to code correctly and also to correct denied claims. Nevertheless, one study estimates that small practices will suffer a decrease in productivity from $8,500 to $20,250, and medium practices will suffer productivity decreases of $72,649 to $166,649. Large practices can expect productivity losses from $736,487 to more than $1.5 million.
To succeed in making the transition to ICD-10 denial management as painless as possible, the process for claims denial management cannot wait even one day more.
Advantages to patient care and disease will be a derivative of ICD-10 coding because of its specificity, but many providers are viewing implementation just as everyone with a computer system fretted over the never seen Y2K disaster. If you are in this category, you should worry as time is running out.
Awareness and preparation are the keys to mitigating losses from delayed and denied payments. Break the denial management process into smaller pieces so that no task is overwhelming. When your billing function is properly prepared in terms of people, processes, and technology the better prepared your practice will be in responding to changes that are coming.
The beauty of a claims denial management system is its ability to point out “hot spots” in your claims filing process. A sound claims denial management system looks at everything and reports to you quantitatively at where you have gone off-track. It may be wrong registration data – incorrect ID number or leaving out the gender. Or, insurance could deny a claim if it the ICD code is not specific enough.
RevenueXL is a company that works with medical practices ranging in size from solo providers to large group practices. We have solutions for claims denial management ranging from complete software solutions, workflow analysis and solutions for electronic medical records, medical billing, medical coding, coding audits, and denied claims management. Call RevenueXL now at 888-461-9998 to learn how we can help you prepare for ICD-10 implementation.
Patient medical debt is a growing trend in the United States. Surveys conducted by the Commonwealth Fund indicate that around 41 percent of working-age Americans were in medical debt as of 2012, and many of those individuals struggle to pay off that debt. Medical debt can be disastrous to patients, resulting in dire financial circumstances such as foreclosure or bankruptcy in extreme cases.
Medical debt is also bad for providers. Though healthcare spending has risen since 1990--making a jump from $2,854 per person to $8,915 per person in 2012--provider bad debt is also rising. Many experts blame the growing self-pay market and out-of-pocket debt for financial instability for healthcare providers of all sizes. New industry guidelines and updated IRS regulations are expected to address patient debt issues, and there are many things medical offices can do to resolve the issue on a case-by-case basis.
Organizations such as the Healthcare Financial Management Association and ACA International worked together to develop a set of voluntary industry guidelines for patient billing. The president of HFMA calls the guidelines common sense measures. The guidelines include standards such as:
The guidelines were announced on January 15, 2014. Experts believe the guidelines will be widely adopted by providers.
Changes mandated by the Affordable Healthcare Act are expected to be issued by the IRS soon. Those changes will include language that reduces abusive collection activities and requires some hospitals to inform patients about eligibility rules and availability of financial assistance. Non-profit hospitals would also be unable to charge private-pay patients over the discounted insurance rate for services.
Small- and medium-sized offices can't reduce everyone's bill or wave copays for every patient. Not only is that illegal, but it would also put providers out of business. Still, there are things providers can do to help reduce the impact of medical debt on patients.
For information about expediting medical claims with electronic billing software or organizing your office's health records with EHR solutions, contact RevenueXL for a free consultation.
