Coding and billing is like a jigsaw puzzle. If one piece is missing (or jammed into the wrong space), the final result is a failure. And missing puzzle pieces in medical coding can result in million-dollar losses.
No one can say for sure how much money billing failures end up costing medical practices, but it’s estimated that a 1% write-off can cost an average-sized hospital $3 million a year. And each additional percentage point results in another $3 million loss.
How common are mistakes? According to one report, auditors hired by insurance companies found errors in more than 90% of the hospital bills they looked at. Granted, the inference of this particular analysis was that many of the so-called mistakes were nefarious attempts to overcharge patients and payers. But as anyone who’s ever been involved in the process can tell you, there’s a lot that can go wrong, even for those with the purest of intentions.
One result, according to the American Academy of Family Physicians, is that the average denial rate across health care is between 5% and 10%.
Not surprisingly, say experts, coding issues tend to be at or near the top of the list of things that go wrong.
The somewhat daunting advice for those going into the field is to stay up to date on the tens of thousands of existing (and ever-changing) codes, which, out of necessity, must “accommodate modifications in healthcare regulations, newfound illnesses, and new treatments for illnesses and conditions.”
On top of that, say experts, you need to always be sure to code each diagnosis to its highest level (the maximum number of digits for that code), or reimbursements will fall short. To be truly confident, say others, consider having a “certified coder” on staff, or even outsourcing coding.
When things go wrong, physicians are often culpable, too. They may fail to adequately document treatments, or they may write so illegibly that they make coders’ jobs nearly impossible.
Uncovered and unpaid
Another surprisingly common mistake: submitting claims for services that aren’t covered by the patient’s insurance. It may sound inscrutable, since billing specialists are expected to always verify coverage.
But any given patient’s insurance might change unexpectedly at any time, sometimes unbeknownst to the patient. And in a busy office, it’s easy for things to slip by.
Billing specialists should be checking and double-checking coverage every time, but the fact is, only about a quarter of all practices say they always check insurance eligibility on return visits.
The diagnosis and treatment are correctly coded, and the service is covered. What else can go wrong?
Plenty, because if one piece of information is entered incorrectly, the claim will be kicked back. It happens every day. A birth year is listed as 1965 instead of 1956. An avenue becomes a street. Deborah Peirce becomes Deborah Pierce. Or Dr. Johnston suddenly becomes Dr. Johnson.
Often, information is left out entirely. The most common omissions include date of accident, date of medical emergency and date of onset. The obvious solution? To always scrupulously examine all claims for missing information and required supporting documentation.
Late claims and duplicate claims are two other common problems. The frequency with which both occur suggests just how complex and burdensome it can be to always file accurate and timely claims.
Solving the puzzle
QueueLogix can help tame the complexity by turning technology into an asset, instead of a burden.
To effectively and efficiently manage revenue cycle management, hospitals and practices need to ensure that information flows smoothly and easily among physicians, coders, office managers, and administrative staff — a lofty and likely unreachable goal in the typical siloed environment.
QueueLogix uses customizable solutions to connect frontline patient encounters with back-end business processes in real time, so, for example, symptoms are diagnosed and coded simultaneously. Additionally, QueueLogix solutions can efficiently process information regarding patient exams, documentation, and billing, and rapidly double-check for accuracy, to eliminate expensive and avoidable errors.
QueueLogix also delivers “actionable intelligence,” harnessing the power of electronic medical records (EMRs) in ways that most organizations haven’t experienced or even imagined.
Their software unlocks and leverages the largely untapped treasure trove of data contained in EMRs. So, for example, instead of burdening team members with the difficult task of remembering thousands of rules, actionable intelligence generates targeted notifications that alert personnel only when the time and situation call for it, such as when a particular payer requires a specific modifier.
The end result is a system that reduces the hours it takes to manage coding and billing, but one that improves the speed, accuracy and volume of payments.