Any physician would be happy to get maximum reimbursements for the service that he/she rendered. But, the present circumstances in the United States demands physicians not only be great healthcare professionals, but also be smart enough to earn maximum reimbursements in medical billing. Now, getting maximum payouts is in the hands of the physician and not just the insurance carrier. Let me list the prime factors that can affect maximum reimbursements for your service.

1. Non-participation with insurance carriers: It is inevitable for physicians to get credentialed or become participating with all major insurance carriers. Non-participation with medicare and Medicaid leads to denial whereas other commercial carriers pay lesser than you deserve for the service that you rendered. So, choose physician credentialing for enhanced payout.

1. Clinical documentation: In most of the cases of denials or underpayment, improper clinical documentation is a reason.  Improper clinical documentation with errors or insufficient documentation can be a cause for processing errors, particularly in medical billing and coding, affecting reimbursements.

1. 3. Processing errors: The most important and the difficult to avoid is the processing errors. This includes all errors in processing starting with data entry till the processing of the claims, including patient demographics, coding, charge entry etc.,  It is essential to keep track of the processing errors and find ways to eliminate/ reduce such errors that can affect payment.

1. 4. Healthcare implementations: The U.S. healthcare industry is facing the greatest challenges in the form of healthcare implementations. The approaching deadlines and the efforts required to implement the same is scaring physicians across the United States. Even then, it is essential to follow the suggestions put forth by the government and allied bodies in order to improve the quality of healthcare.  The CMS encourages timely healthcare implementations by providing incentives and penalizing for not following the schedule. Therefore, physicians have to be cautious in making necessary Implementations on time to avoid penalty.

1. 5. Timely Filing Limit: TFL is a valid point that lays emphasis on timely filing of the claims to insurance carriers. Though the TFL varies for different insurance carriers, failing to submit claims before the TFL will result in the denial of claims by all insurance carriers.

1. Failing to appeal for claims: If the genuine claims are denied or underpaid, it is essential to appeal for reconsideration, which provides the possibility of getting the claims accepted or paid better, based on the appeal. Failing to do so is a loss to the practice, affecting the reimbursements.

Ensure that you meet the terms with the above mentioned points to assure maximum reimbursements and improved collections in medical billing.  It is also essential that physicians periodically look out for any updates from the government and allied organizations that can affect reimbursements.

With the medical billing and coding industry evolving and changing at an unprecedented rate, the focus has shifted from simple (paper?) to complex and complete documentation – be it on the clinical or process side. As and when new changes get announced, there is more and more emphasis on the necessity for proper documentation.

Many consider documentation a pain and fail to understand the importance of it.  It may not be required immediately, but it can be safely presumed that it would come in handy at a future point in time. Let me highlight some instances where proper documentation is not only an option but a must-have.

Insurance Auditing:

The most frightening nightmare that a practice can have is – the insurance audit. With the advent of the RACs, MICs and ZPICs, every Healthcare entity is at risk of being audited and penalized.  The only solution that can alleviate this problem a little is by having proper documentation.  Also, the Appeals data of the past 2 years show that Healthcare professionals with complete and proper documentation had a very high success rate when they appeal the ruling made by the Auditors.  It certainly pays to be methodical and careful with documentation instead of losing both past and potential future revenues to Audits.

Accurate medical billing and coding:

Documentation is the key to accurate billing and coding.  Many entities follow the simple rule – ‘If it is not documented, it cannot be Coded or Billed’.  This policy is followed not only to promote ‘Best Practices’ in Billing, but also to avoid later complications during Audits. Any omission of details while documenting can lead to under payments and/or even denials.  Many Providers realize the extent of revenue loss incurred by them due to poor documentation, only when they go through an audit of their past claims.  Moreover, ICD-10 being much more detailed in its Code-sets, demands clinical documentation to be precise in order to get accurate payments.

Process Improvement:

Process improvement and re-engineering are the key to evolve with the changing times for any process, including medical billing and coding. Failure to improve or re-engineer processes in accordance to new guidelines and rules, results in denials and underpayments which ultimately lead to the demise of the entity.  There have been several instances where Healthcare institutions declared bankruptcy just because of inefficient processes, improper documentation or an inability to change with the times.

Appeal for denied claims:

Appeals work at two levels, with the Insurance payer as well as when being Audited by RACs, MICs or ZPICs.  When the documentation is good, denials can be re-filed and appealed with more authority which results in faster and higher payments.  Once a track record for excellent documentation is established, the Payers accede to review requests faster.

Reporting & decision making:

Clinical documentation supports medical research by providing all essential information and has been very helpful for healthcare agencies like the CDC and DHHS in disease management and faster decision making.  The case of the H1N1 virus is a good example of how proper documentation helped the agencies in responding promptly with advise and treatment protocols.

The need for documentation in medical billing doesn’t end with this short list. Every process in medical billing and coding needs proper and complete documentation that can help in the filing of clean claims and improve reimbursements.

If you are a medical practice that has chosen to outsource medical billing and coding functions, it is essential that you need to follow certain guidelines that will make outsourcing a success for you.

• Choosing the right medical billing company to outsource: The success of your outsourcing venture depends upon on the service provider that you have chosen. So, be specific with your requirements while choosing the company to outsource. Choose a medical billing company that has in-depth knowledge, good experience in the field and proven track of performance.
• Deciding the deliverables: After you have chosen a good medical billing company for outsourcing, the next important step is to decide the deliverables that you require/expect from your service provider, discuss the vital factors that determine the performance like turn-around-time, accuracy percentage and level of support that the medical billing company can provide you. Keep it clear in the agreement.
• Monitoring performance: Make sure that the medical billing company provides consistent performance. Analyze the monthly performance reports to review performance and find the areas of improvement. Maintain proper records for performance and ensure that the performance related issues are addressed immediately.
• Organized communications: Establish streamlined communications with your service provider. It is good to have a dedicated representative for your practice who can handle issues related to medical billing outsourcing, co-ordinate with the service provider and be a bridge between your practice and the service provider. A weekly update on the status can be useful in order to have a check if everything is on right track.
• Mutual assistance: Co-operate with your billing company whenever they need your assistance. With your help, the billing company will be able to perform better and with more ease.  Share the industry updates with them for enhanced operations. Meet the representatives of your service provider once a year or two for a detailed meeting on performance/ issues or challenges to be faced.

Following these suggestions would make your outsourcing venture more successful and help you reap maximum reimbursements from outsourcing medical billing

The U.S healthcare industry is one of the most active segments in the world. The industry often faces great challenges of new process/software implementations while meeting the growing needs of healthcare. The current scenario in the industry requires the healthcare organizations to reduce costs and improvise the processes. Although it is tough to reduce costs in healthcare, medical billing process provides opportunities for healthcare organizations to save cost by outsourcing to medical billing companies.

Medical billing outsourcing is considered a boon to healthcare organizations that find difficulty focusing on medical billing operations and patients simultaneously. But, outsourcing alone is never a solution to healthcare organizations that aims at maximum reimbursements. It is essential to outsource medical billing and coding functions to medical billing specialists in the field that can provide outstanding deliverables. Experienced medical billing specialists can be more productive and can face the challenges in billing easily. After outsourcing medical billing and coding functions to medical billing specialists, healthcare organizations shouldn’t stop monitoring the billing performance. Instead, it should keep track of the performance by regularly co-ordinating with the medical billing specialists. The Better the service provider performs, better will be reimbursements.

Medical practices reap huge benefits while outsourcing to medical billing specialists. On outsourcing to medical billing specialists, the practice is relieved of the billing hassles and can focus only on patients, translating in to more revenue. Outsourcing medical billing also helps practices in saving operational and administrative costs. When practices outsource to offshore medical billing specialists, it can save up to 40% costs depending upon the service provider’s country and the labor expenses.

Medical billing companies also aid organizations with the new implementations like ICD10, EMR/EHR etc that can be of great help. On the whole, outsourcing medical billing and coding functions to medical billing specialists can be profitable to medical practices and healthcare organizations.

After the chaos that the HIPAA 5010 implementation has created in the industry, there are multiple unanswered questions before us. It all revolves around two factors – Healthcare implementations and the day to day billing operations. Are we striking proper balance between the two? Are we taking the medical billing and coding implementations seriously? A genuine answer to the questions would be a big ‘no’ from most of us. We all try to cross the bridge as it comes, without analyzing the depth of impact it may have on the day to day operations and vice versa. We try to keep pace with the regular activities until we dodge them aside only to run behind any implementation, while it nears deadline.

Keeping pace with healthcare implementations while sustaining billing productivity:

Starting from HIPAA 5010, we have many other implementations like ICD10 and EHR on Queue that need be worked out before 2013 & 2015 respectively. Every day, it’s becoming tough for the healthcare professionals to adapt to the rapidly changing industry, with ‘uncertainty’ spreading across like an epidemic. Now, it’s high time we streamline the work flow and make room for advancements in our daily schedule.

Here are a few suggestions for physicians and medical billing companies to keep pace with implementations/projects:

• Allot specific time for gathering industry updates
• Enroll for daily email alerts from reliable healthcare organizations
• Discuss with colleagues, social networking peers about the latest developments in healthcare billing on  a regular basis
• Attend important events and meets that discusses on medical billing issues and developments
• Set up project plan & conduct weekly reviews for any implementation like ICD10
• Provide training to staff on a daily basis
• Testing is an important phase before any project goes live. Test every system before it goes live, find and fix the flaws in the system
• During the post implementation phase, monitor and maintain system. Analyze & measure user experience & efficiency with people involved. Document the observations which will provide input for future enhancements

When you are planned and well informed, you can easily manage the medical billing and coding operations and the implementations simultaneously without having to sacrifice the other.

The Speaker of the House of Representatives has announced that the House GOP Caucus has agreed to pass the short-term (two month) SGR fix.  The House could pass the legislation as early as tomorrow but it is also possible that the vote will have to wait until next week.  The bill that is expected to be passed would continue the 2011 Conversion Factor for the Medicare Physician Fee Schedule until March 1.  The Congress will have to pass another “fix” between now and February 29th in order to prevent an SGR related cut on March 1st.

The Holiday Season is here and whilst the entire US and most people across the globe celebrate the festive spirit of the season, there is one large group that gets into a fear psychosis around this time of the year – Not the airline passengers that need to go through increased security by the TSA, but Medicare beneficiaries and their Care Providers – the Physicians.

Every year around this time in December, the SGR rate cut ‘circus’ begins and is brandished at the Practitioners and consequently their Medicare patients.  This year has been no exception.  The Congress passed a resolution on 13^th December putting ‘on hold’ the rate cut for the next two years and actually increasing the Medicare rates by 1% for 2012, but on 20^th December the Senate rejected it.  Though there is wide bipartisan support for repealing the rate cuts, the Congress and Senate do not share the same views on how to pay for this repeal.  Now that the Senate has adjourned for the Holiday Season till 23^rd January (unless the Senate re-convenes for a special session in the first week of January), the slim hope that there could be a solution to this problem before the New Year, unlike previous years, has once again vanished.

The rate cut of 27.4% will come into effect from 1^st January, 2012.  CMS has already announced that Medicare will keep all claims on hold for the first 10 working days of the year so that it can prevent a re-hash of last year, when all the claims were paid with the rate cut and once it was repealed, had to be re-processed at the new rates, resulting in huge administrative costs for CMS and its MACs.  Though CMS has tried to prevent this wasteful expenditure, there is every chance that it might not be successful.

The Sustainable Growth Rate (SGR) was part of the Balanced Budget Act which was passed in 1997 to control spending by Medicare on Physician services.  The SGR was supposed to limit the rate at which Medicare spending grew every year to within the GDP growth rate.  But the real problem has been that the Healthcare spending in the US has far outstripped the GDP growth rate in the past decade.  This resulted in ever larger spending cuts proposed every year – but deferred every year by special legislation.  The result is that after 12 years of consistent deferments, the rate cut today stands at an exorbitant 27.4%.  The Congress and the Senate have failed to reach a consensus on permanently fixing this problem.  Healthcare associations like the AAFP, AMA, HBMA, MGMA, HFMA and others have lobbied and consistently spoken against this method.  Some of them like the AAFP have suggested a 5 year moratorium on rate cuts so that alternative methods of ‘spending cuts’ can be tested over a period of time before replacing the SGR.

If the rate cut goes through without any legislation from the Hill, then Physicians will stop caring for Medicare beneficiaries.  There is also a possibility that the instances of fraud/abuse could increase because of this pressure, even though there is an increase in vigilance on the Physicians through the extension of the RAC program.  On the other hand, this would also put pressure on other Healthcare entities like RCM and Medical Billing companies that service the Physicians.  The rate cut and the consequent loss of revenue for the Physicians would translate to requests for realigning the fees for revenue cycle management and medical billing/Coding services from these Physicians.  This would result in a vicious cycle of payment cuts and unemployment in an economy that is slowly trying to recover.

The latest OECD data shows that the US spends $ 3,000 more per individual per annum when compared to other developed nations.  The total of $ 900 billion more spent on Healthcare (compared to other developed nations), essentially does not mean better healthcare for the individual.  By one estimate, wasteful elective procedures and diagnostic tests alone account for $200 billion annually.  When compared to this figure, the SGR rate cut of 27.4% would fetch only about $16 billion per annum.  The more prudent way to approach and solve this problem will be to plug the ‘holes’ in the system rather than trying to cut reimbursement to the already diminishing number of Primary Care physicians.

The call is now to the lawmakers on the Hill to set aside their petty differences and make a meaningful legislation that has some lasting impact on Medicare and its beneficiaries.  Even if it is not achieved before the end of this year, the hope is that the first weeks of the next year could ring in a change so that better sense prevails.

Happy Holidays!!!

EHR has been around for more than 15 years now, but only in the last couple of years has there been an active and conscious move towards adoption.  The impetus was provided by the ARRA Act that incentivized the adoption and implementation of the EHR in Clinical practices.  Though the deadline for implementation is 2015, clinical informatics confirms that more than 50% of the surveyed healthcare professionals are already using EHR for their practice and more than 90% of them are happy and as adept at using the EHR as they were with the paper SuperBills. But, does this mean that the Practices are complying fully and satisfying the main objectives of the incentive plan for EHR adoption? The answer to that question is self-evident. Moreover, just implementing the EHR is beneficial to the Providers to a small extent, but does not meet with the final objectives of either the ARRA Act or CMS.   EHR shouldn’t be implemented out of the fear of getting penalized (after 2015) or for the sake of incentives. EHR should be considered as an aid that makes the delivery of healthcare effective. CMS has clearly stated that the mere buying of the EHR product will not satisfy the needs of the meaningful use.

The agenda behind EHR implementation is to have a de-centralized but inter-operable system for streamlining healthcare delivery and improving quality of care thereby serving patients better.  This is achieved through the inter-operability that exists between the Scheduler, EHR, e-prescribing tool, Medical Billing software and the ability to receive lab and/or radiology reports.  The EHR is also designed to enable greater portability of patient information with enhanced security.    The advantages for CMS is the ability to easily cull data from Providers across the country and process it into actionable information.  A classic example would be something like data about the mean age of onset of diseases partially attributed to lifestyle like Diabetes Mellitus.  With this data, CMS can convert it into actionable information for preventative healthcare guidelines and suggest a rewarding mechanism for patients in the form of ‘credits’ in their next premiums.

Let us discuss the major requirements of ’Meaningful Use‘:

• Buying of a certified EHR with customizable templates and supports inter-operability with other systems like e-prescribing, medical billing software etc,
• Effective use of clinical decision support like the Coding suggestions, Level of care suggestions in E/M procedures etc.
• Recording the observations for future use
• Use EHR for collecting the healthcare statistics in order to report to CMS and other Healthcare entities like the CDC for improving quality of care.
• Securing the electronic information from any data leakage.

The EHR also has the capability of simplifying the whole Medical Billing process:

Since documentation plays such an important part in Claims being paid faster, EHR are actually designed to prompt and guide a Provider with key steps during the consultation.  The Provider has the choice to ignore these recommendations, but in most instances the adoption of the EHR has actually increased the ‘first pass rates’ of the claims.

Most of the EHR available today also come bundled with its own PMS.  This ensures that some of the data entry functions are now automated since the data that is entered at the ‘Point of Service’ or during the encounter just flows seamlessly into the PMS.

Most EHRs also come bundled with CAC tools and CCI edits that either partially auto code based on the data entered by the Provider or prompt him with a choice of the most appropriate codes.

The combination of the EHR-PMS bundle is directly integrated with a Clearing house and at the click of a button, claims are transmitted to the Payer.

The EHR-PMS is also able to handle the inbound ERAs and some of the higher versions have auto cash-posting abilities as well.

All these features of the EHR-PMS combo makes the entire medical billing process much simpler with manual intervention required only for Audits and for AR follow-up/Denial Management.  This ensures that the claims are paid faster, more consistently with minimal denials.

To conclude, it should be remembered that the EHR is a tool.  As with any tool, it is only as powerful as the skill level of the user.  If properly integrated and utilized, the EHR has the potential to offer some major advantages and savings to the Healthcare industry.

We are going to discuss now, about the features that good medical claims processing – the medical billing software should possess. Well, most of us would have already chosen a software that suits our needs or at least learnt to survive with a software that’s chosen in rush. Some of us may even be in look out for good medical billing software as well. Whatever be the case, we should know the latest advancements that different medical claims processing software companies have introduced in the recent years. Is it really important to spend time in analyzing the features to choose suitable medical claims processing software? Certainly. Experienced medical claims processing professionals would have realized that medical billing software plays a major role in healthcare revenue cycle management process and aids in every step towards collecting money. The better the features are, you will get maximized benefits. But, it is tough to find all advanced features in the same software. The best option is to go for user friendly software that has the most essential features. Let’s analyze the importance of medical claims processing software & review the vital features.

How medical claims processing software helps in enhanced process/ collections?

• Different medical billing software have their own features that will enable you to do certain function that other software doesn’t. This will give you the competitive edge over others, resulting in enhanced reimbursements.
• Certain software will enable you to perform the entire process with the same medical claims billing software, acting as a one stop shop for your medical claims billing needs. This will avoid discomfort arising from switching over to multiple systems at the same time.
• Software that can give you proper insight about your process & performance will aid in revenue improvement, whereas other software may not provide this insight and requires human intelligence to find things out, thereby wasting valuable time which could have been spent in doing productive work.

Features that help in medical billing process enhancement:

• The depth of report that can be provided for appointment scheduling can make the practice more profitable.

For an instance, when a particular patient books for but often skips appointments can be easily tracked and be fined, since the physician is booked for that period & the patient didn’t turn up resulting in waste of time in which the physician could have treated another patient. Features like this will give you better idea about how your appointments are doing & eliminate messy appointments and will make your practice more manageable right from the beginning.

• Good medical billing software should control errors in charge entry. The review screen with visual editing features for charge entry will enable the charge entry professionals to have a look at final screen and eliminate errors. For recurrent appointments the complete patient encounter information should be updated to avoid data entry again.
• Denial management reporting features that provides exhaustive report on denials can be useful to a great extent. It will enable AR analysts to manage denials efficiently and save time as well.

Advanced Features:

• EMR/ EHR: EMR/ EHR implementation is talk of the nation now. We need to implement it before 2015 to get along with industry standards. We need to therefore look for medical claims processing software that can integrate with EMR/EHR. EMR software with inbuilt medical claims processing software will be a good option.
• Document Management System: This is an essential feature that would contain complete repository of vital documents mapped to the patient accounts. This will help in handling denials effectively since analyzing will be easy with all important information together. Moreover, if the card copies of patients are scanned and uploaded to the system, it will help in verifying insurance and eliminating errors due to improper insurance eligibility verification
• Manipulation restrictions: Medical billing and coding fraudulent activities are becoming common these days. Since the medical billing software is the claims processing medium, it is good to choose software that is secure as well as restricts manipulations in system.
• Backup Management: Software that has backup management features will help in information management even at times of emergencies
• Dash board features: Dashboard feature is a smart functionally that will give a snapshot of all metrics, to-do list, revenue performance etc., in the ‘startup’ screen itself. This will give an idea of performance and your activities in a glimpse.
• Work flow allocation: Some medical claims processing software enables work flow allocation which is an important segment of handling task. Work can be allocated to different users and managed. The users & the admin would get alerts regarding task and the status would be automatically updated. This vital feature organizes workflow, improves efficiency  and provides better results.

Now, choose the software that has maximum essential features and fits your practice requirements as well. Go for multiples demos from medical billing software vendors, ask your peers  about their experience with the software and then decide a good software.

e-prescribing, as clearly explained by CMS, ‘is the ability of the qualified physicians to electronically generate an understandable prescription and send directly or through commercial pharmacy network to a participating pharmacy’. The main reason behind implementation of e-prescription is to reduce medication errors & improve quality of care in the United States.

Latest research reports on medical errors indicate that every year in the U.S. 1.5 million people are affected and thousands of people die due to ‘medication errors’. The alarming numbers reveal the need to follow a prescribing system that improves the accuracy of prescription. That’s why there is a strong push from the government of the United States to implement e-prescription system.

‘e-prescription implementation – incentive & penalty plan’ put forth by CMS.

CMS encourages physicians to implement the new electronic prescribing system by providing financial incentives if they implement e-prescribing on time and penalizing if they don’t.

Implementing e-prescription:

• Determine your practice requirements to implement e-prescribing
• Educate your patients & your staff, the need for electronic prescription if they resist it.
• Give adequate training to the staff to cope with the changes.
• Keep your vendor aware of the changes so that they are not surprised with an e-prescription from your facility/practice.
• Research and find suitable e-prescribing software that will suit future requirements of ANSI 5010, ICD -10 implementation & most importantly EMR.

Challenges faced while implementing e-prescribing:

• Dependency on system requirements for e-prescribing
• Information security concerns and remote access limitations
• Resistance from patients and staff

While implementing e-prescription, physicians may face many other challenges as well. But e-prescribing provides multiple benefits to physicians that make it worth implementing.

Key Benefits of e-prescribing:

• Legibility of prescription and reduced medical errors
• Compatible for EMR
• Reporting abilities – capability to generate medication report for healthcare analytics
• Time saving and avoids pharmacy call backs
• Cost effective
• Review of medication history that results in enhanced accuracy in prescription
• Alerts – For instance, e-prescribing system alerts physicians for alternative drugs that are more efficient & cost-effective. Warnings – It provides warnings for drug refills so that refills are made quickly
• Greater convenience to physicians and patients
• Improved Patient safety and quality of care

Just adapting an e-prescription alone will not speak success stories.  Diligence & routine check up on the functionality of the system, data analysis, closely monitoring patient’s tolerance etc will boost the efficiency there by reducing cost & maximizing your benefits.