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1. Medical Coding

The primary responsibility of the coding process is capturing all possible valid revenue opportunities, from the physician’s documentation. This entails capturing all procedures and relevant diagnosis codes,with the highest level of specificity. It is always the responsibility of the coder to check for possible documentation deficiencies by the physician. This may be an added revenue opportunity if it was indeed performed and not documented.

2. Inventory Control

Medical billing is all about accounting and collecting for every patient. Tallying up the charts against the patient schedule and visit roster is the most common step. The questions to be asked are: Were all procedures and visits charted? Have all charts been coded? Were all coded charts billed? A seamless view into this billing workflow covering the above processes can net thousands of additional dollars every year. A robust workflow platform that can capture this chart flow and show stagnancy levels at every step helps avoid costly losses.

3. Transmission

Performed at the clearing agency stage, this is relatively easy to track, given the tools available with the clearing house and tight integration with the billing system. However, rejected charges being left out to hang dry is not uncommon. Claims that failed a payer or a submission edit are the easiest and less expensive ones to resolve. The ability to work on the rejection files of various clearing houses and familiarity with the reports and nomenclature are added advantages.

4. Underpaid Claims

Any decent billing system will provide features to catch underpaid claims. By setting alerts based on fee schedules and being able to customize it at the insurance level, will help trap instances that rob the practice of its due. A vigilant payment poster and a clever system can combine to eliminate this leak. Usually resolving this is also a straightforward process, as there will be possible precedence to use.

5. Secondaries and Balance Billing

Billing secondaries and balance billing the patient diligently are other easy processes to miss. Setting the system to bill automatically, and periodically auditing for secondary billing and payments, can make the difference between a good and a great collection performance. The front office and patient interaction teams must be trained to request for the patient’s possible secondary information, during every possible interaction.

Offering patients a variety of easy to pay options, portals and safe payment gateways can enhance the patient experience, while maintaining a healthy patient relationship

6. Denials, TFL and Appeals

Working billing and coding denials using a structured approach, involves a tool that guides users on appropriate action, can do wonders to reimbursement performance. It is imperative to have an effective denial resolution program that can prioritize, set alerts for review, provide a daily plan and guide on resolution steps. A specific library of denials and the appropriate action required for resolution are important, and can be updated and integrated with the denial resolution platform. Daily flushing of data to reflect only the truly unpaid and work-ready claims, can cut enormous costs of working wasteful claims.

Insightful reporting that provides effectiveness of the denial process, is indispensable to know the cost of collection and “collected v/s write off” comparisons.

Other areas that usually slip through the cracks are TFLs and appeals. Using systems that can support easy appeal letter process and warn of TFL occurrences are a must in an effective medical billing company.

7. Eligibility and Benefits Check

Several hospital-based specialties seldom perform this task, though data shows this to be the biggest denial contributor. Deploying an automated eligibility verification interface supported by a verification specialist payer-wise is single biggest revenue enhancer and denial buster. This step is an effective precursor to help patient balance resolution from a previous visit.