It’s no secret that healthcare providers have long faced difficulties getting paid for services rendered. However, new trends have made that task even more onerous:
Beyond the obvious source of risk – patients without the financial means to cover their full deductible – HDHPs come with another unique RCM workflow challenge: They demand precise processes for eligibility verification and payment estimation. Practices that fail to pre-emptively account for the unique properties of patient HDHPs are oftentimes met with unexpectedly-low reimbursements or claims that are denied altogether. At this point, the only available course of action is to turn to the patient for additional payment. This not only extends the life of the outstanding receivable and the effort that goes into reimbursement, but it also puts front-desk workers in a potentially contentious – and frequently low-reward – interaction with your customers.
Many of the same risks affecting HDHPs apply to co-insurance. Even after patients meet their deductibles and full coverage commences, many will still need to pay a certain percentage to meet out-of-pocket maximums, based on the terms of their plans. In these circumstances, payment estimation will continue to be important, because the complex nature of insurance has left many patients unsure of just how they work, when they kick in, and how much they cover. Accurate and proactive payment estimations can be the crucial link your staff needs to accurately and clearly explain to confused patients what they’re required to cover, then and there. Estimations also prevent sticker shock and, given the right front-desk processes, go a long way toward ensuring payment at the time of service or, even, setting up arrangements for payment afterward.
From start to finish, every process along the care continuum needs to function in perfect synchronization. This is because value-based care, unlike fee-for-service, factors healthcare outcomes into reimbursement. Practices already participating in CMS’ MACRA/MIPS program probably have some idea of how VBC works. But, as more commercial insurers follow Medicare’s lead (and they are), it’s likely that this new method of reimbursement will touch a far greater share of groups. VBC requires practices to identify specific clinical quality measures (CQMs) and then demonstrate their performance against them, in order to be awarded higher (or lower) reimbursements. This requires EHR and practice management (PM) solutions that meticulously document patient data, record results of follow-up exams and questionnaires, and log and organize other information that clearly shows how the practice facilitated better outcomes. Real-time dashboards and drill-down reports that detail these metrics are instrumental in helping practices track their performance throughout reporting periods and maintain positive levels. Finally, some technology partners offer unique support programs that provide MIPS-focused education, setup consultation, monitoring, and, even, submission assistance to better ensure successful participation in complex and ever-changing federal programs.
According to the Healthcare Business Management Association (HBMA), a single provider can lose $40,000 each year to downcoding and the problem can be even more significant for specialty practices. The main reason is out of fear of penalties associated with overcoding or unbundling. In effect, these practices are preemptively penalizing themselves. And, yes, overcoding is a compliance risk that needs to be taken seriously. However, downcoding is both a compliance and revenue risk that must be taken seriously.
Another common source of loss for practices is the fact that the support staff who handle coding simply can’t be sure of what observations and services occurred in the exam room. This highlights a simple truth about the coding lifecycle that we explored in a previous post on this blog: Medical coding and billing is a never-ending exercise in precision and coordination. Your support staff shouldn't need to be in the exam room to accurately code for the services; the documentation collected at the time of service should tell the full story of what happened.
Better coding and documentation starts with the use of an electronic health record (EHR) system that has a robust clinical library. Further, the data collected needs to be highly accessible, so that all the details necessary to create a truly accurate claim are available to support staff. Moreover, claims need to be scrubbed clean. The information needs to be properly verified, and any unique payer formatting preferences need to be strictly adhered to. Ideally, you'll have a practice manager and clearinghouse that helps you efficiently optimize your claims for the myriad requirements of various payers.
If a claim gets rejected, it shouldn't sit in a drawer and collect dust. It needs to be evaluated, and steps must be taken to rectify any issues that may be barring your practice's access to its hard-earned revenue. And, when needed, unpaid claims should be outsourced to a professional collections agency for ethical and sensitive action.
Practices should consider using a Revenue Cycle Management (RCM) service that focuses on their specialty, not to mention the less-than-low-hanging-fruit that’s stalled in their billing process. Look for an RCM service that offers comprehensive assistance, from end-to-end, including process examination and remediation, certified coding analysis and education, full denial management, and professional collection services. Finally, it’s important to find an RCM group that functions as a true partner, complete with dedicated account managers, regular reporting and transparency, and offers its services in a cost-neutral model. Your practice will be less stressful, more successful and enjoy far more stability for it!