Key Issues in Medical Practice Revenue Cycle Management

by | Published on Aug 19, 2016 | Insurance Verification and Authorizations

Medical Practice
Share this:

Success in managing the revenue cycle depends on efficient handling of all the processes from patient enrollment and medical eligibility verification to medical coding and billing and payment collection. Accurate capture of all the information at each stage and proper interaction with patients and payers is necessary to ensure smooth flow of all these processes. However, there are many challenges involved in all the steps of revenue cycle management. Understanding and managing them efficiently is the key to optimizing reimbursement and ensuring smooth workflow.

Patient eligibility verification and authorization: Checking insurance eligibility involves verifying if the patient is covered including primary and additional insurance, whether the demographic details are correct, eligibility date, maximum allowable visits and the patient’s share of costs. These details need to be checked for new patients as well as for existing patients at each visit. For instance, dental insurance verification is particularly complex with the large number of insurance programs, ever-changing plans and eligibility rules and growing number of providers in PPO networks.

Lack of proper eligibility verification is one of the most common reasons for claim denial. Most insurers require preauthorization for non-emergency procedures and products and insurance authorization has to be obtained in a timely manner.

Informing patients about financial responsibility: Every practice should have a payment policy and patients should be told about their financial responsibility at the outset. This will avoid confusion and make it easier to manage risks of non-payment or refusal to pay. A payment policy should provide clarity on:

  • Date on which payment is due
  • Payment responsibility – self-pay patients are responsible for the entire bill while insured patients will have co-pays, deductibles, and out-of-pocket payments
  • How co-pays and deductibles are handled and collected
  • In what form payment is accepted
  • Nonpayment policy

Medical coding and billing: Errors in medical coding leads to improper billing practices, payment delays and/or loss of revenue. ICD-10-CM coding is complex and only expert coders can assign the right codes for the services provided. The American Health Information Management Association (AHIMA) recently listed the top coding challenges as incorrect application of the seventh characters for trauma and fracture codes, improper use of procedure codes that drive a diagnostic related group, misidentifying respiratory failure, mistaking the use of guidance tools, and insufficiently documenting devices, components, and grafting materials.

Payer requirements: Physicians practices need to stay current with payer requirements. Not doing so will result in sluggish cash flow, high claim rejection rates and additional administrative expenses.

The ideal way to ensure efficiency in all these processes is to partner with a reliable medical billing and coding company. As there are many medical coding companies out there, physicians need to scrutinize service providers carefully and choose a proactive vendor with professional medical coders and billing specialists onboard. Making the right choice can ensure the right tools and resources to streamline practice management, proper claim submission and maximum collections.

Meghann Drella

Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.

More from This Author