A practice with a well-functioning revenue cycle will have mechanisms in place to ensure that its patient records align with those of the insurers’. A proactive practice will remind patients via automated email or text message to update any information, such as address changes, in the days leading up to their next appointment. Some advanced Practice Management solutions (PM) offer patients the ability to accomplish demographic and/or history updates via online portals or, even, in-office kiosks. At a minimum, though, practices should implement front-desk processes to ensure that staff collect changes and update records before claims are generated.
While this might represent the “low-hanging fruit” of measures available for improving RCM, a single discrepancy between the patient information the insurer has on record and the information you include in a claim could lead to a denial, even for an otherwise squeaky-clean claim with all the right codes. And, if it’s a critical issue that can be remedied with little or no involvement from your staff, it’s definitely fruit that should be picked!
Better front-desk workflows don't just improve practice efficiency; they improve RCM performance. A smart practice verifies insurance eligibility prior to the patient's visit so that it can generate an accurate payment estimation. This is important for two reasons:
Similarly, pre-authorizations and referrals typically required for HMOs should be preemptively verified to avoid an oversight that could lead to a rejected claim.
Regarding the actual process of medical coding, an Electronic Health Record (EHR) system with a robust specialty library is crucial for providing physicians with the full depth of medical codes required for accurate and payable claims. High-performing practices tap into this deep clinical content to make it easy for clinicians to record and justify CPT, ICD and HCPCS codes during an encounter.
Express documentation as a native function of EHR helps practitioners quickly, accurately and consistently document patient encounters. Robust EHRs provide customizable functionality that can instantly document key phrases or even entire passages with quick keystrokes and shortcuts, and associate them with specific medical codes. This information is crucial for demonstrating why certain codes were chosen, which is important for the purposes of avoiding over-coding, or conversely, subverting under-coding out of fear of a potential audit.
Practices with healthy RCM lifecycles will have more than one claims-scrubbing process in place. Ideally, the first will be automated – for example, an EHR or practice manager (PM) system with integrated scrubbing can make real-time recommendations, as encounters are documented or claims are created. This helps prevent data-entry errors or accidental use of a wrong code. An effective EHR or PM can even make recommendations for codes that you may not have included but probably should.
The second layer of claims scrubbing involves certified coders proofing claims before final submission to make sure that the format, insurer information, patient data, diagnoses and treatment codes, and evidence of medical necessity are accurate. The expertise of highly-trained, certified coders are not only valuable as stop-gap measures that address insufficient claims on the way out the door, but also as a preventative cure, as their feedback educates providers of common errors that should be avoided or of new requirements that must be implemented. Combined, these two key measures help produce cleaner claims that will result in far fewer rejections.