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Tackling denials in Medical Billing and Coding for Pathology

The challenge faced by pathologists in their quest to maximize collections is crossing the biggest hurdle of claim denials. According to CMS (Center for Medicare and Medicaid Services), over 30% of medical claims that are submitted are either denied, lost, or ignored. No practice or company can actually afford to lose such a whooping percentage of revenue.

When it comes to Medical billing and coding services for pathology, the CMS Medicare physician fee schedule for 2022 already has a reduction of 1% in reimbursement for pathologists. Independent laboratories face a 3% decrease and a 6% decrease for diagnostic testing facilities. This has already reduced the reimbursement for pathologists, and denials shouldn’t be taken lightly in such a scenario.

Reducing denials and increasing collections for your Pathology medical billing and coding can be achieved in 5 ways.

1.Eligibility verification – This is no surprise that eligibility verification is on top when it comes to minimizing denials. According to Change Healthcare’s Denial Index of 2020, claim denials due to registration and eligibility issues account for more than 26.6% and this is the topmost cause of denial in their ranking. A prompt benefit verification at the time of scheduling an appointment can help in reducing eligibility denials. At Quintessence, we strive to create solutions for processes in Medical billing and coding that are usually not prioritized by other RCM leaders. Our RPA BOTs can help obtain faster and more accurate eligibility and benefit information so that no claim is submitted incorrectly.

2.Coding accuracy – The best way to improve coding accuracy is with the help of investing In the right computer-assisted coding platforms. It is a challenge to constantly keep up with coding updates and the need to review documentation thoroughly to code right. With a computer-assisted coding platform, your medical coding is typically hands-free, giving you more time to focus on what is important, patient care. You can opt for plug-and-play coding tools that are available in the market. There are also some unique tools like Quintessence’s Codessence, a machine learning-based coding platform that gives you the best of coding automation as well as a 100% coding audit by coding experts.

3.Payer behaviour – Understanding payer behaviour can help in setting up the entire medical billing and coding process. Every payer has different guidelines with respect to CPT codes, modifiers, Timely filing limit, Prior-authorization, and documentation requirements. It is important to set up payer wise process flow to keep up with different payer policies to prevent any rejections and denials.

4. Root cause analysis – Prevention is better than cure and that’s exactly what root cause analysis helps with. This is a step-by-step work on identifying the various causes of denials and creating strategic solutions to eliminate the same. Root cause analysis is largely dependent on data analytics to determine the cause-effect pain point. Quintessence has curated a 5-step root cause analysis that can identify issues in the front-end and back-end of your medical billing and coding process. To know more, click here.

5.Workflow optimization – This is just a fancy word that actually means to get every process to work in line with each other. Starting all the way from scheduling to payment posting, every scope or aspect of the medical billing and coding process can be fine-tuned by investing in the right tools and solutions. The mix and match of Artificial Intelligence, Robotic Process Automation, and Machine learning bring together an array of solutions for the RCM that healthcare service providers can take advantage of. Quintessence has created solutions that address different scopes of the Revenue cycle management. Our workflow optimization tool Reimburssence works specifically to handle denials and guide accounts receivable specialists in moving the claim towards payment.

According to industry standards, the average denial rate for a practice should be less than 5%, but shockingly practices deal with a denial rate of 10%. If your practice or billing company is looking for an expert to clear your backlogs and improve collections, Quintessence is happy to help!

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