In the U.S., the healthcare industry is constantly transforming. The perception of a lack of correlation between medical care costs and quality has led to a complete transition from the fee for service model to the value-based care model. With multiple headwinds, such as declining reimbursements and the rising cost of hospital care due to the increase in the cost of supplies post-COVID. The great resignation is leading to a problematic situation for healthcare decision-makers.
Healthcare margins are at their lowest point in 20 years. They are finding it difficult when finding both clinical and administrative personnel. Medical billers and coders are the lifelines when it comes to complex reimbursement processes. The medical codes serve as the standard language for healthcare providers and payers and drive the rules around reimbursements. There’s a significant demand for medical coders. Medical billers work on revenue cycle components processes such as patient experience, claims submission, and denial management. Medical coding is also the anchoring discipline when defining the quality of care.
There will be a short supply of healthcare administrative talent for many years, and medical billing and coding offer lucrative career options. Here, we’ll focus on how revenue cycle management will play a critical role in defining the quality of care.
Understanding the basics of medical coding
Medical coding involves the translation of medical diagnoses and procedures into industry-standard codes. These codes serve as the common language between providers and payers. The process is essential for the healthcare payers to understand the disease or ailment the patient has and the procedures taken by the medical practitioner.
In the revenue cycle management, the payers have a prescribed reimbursement amount. The process of medical coding is pretty complex. It requires a comprehensive understanding of medical terminologies. It’s a specialized field requiring intense training and certifications.
Significance of medical coding
Beyond reimbursements, medical coding can be an effective mechanism when understanding the quality of medical care. Here, the revenue cycle management company wants you to focus on critical factors, including,
Aging population
The population in the U.S. again, the demand for medical care, especially for chronic healthcare conditions, will surge. Increased demand for medical care translates into increased demand for medical coders and billers.
Declining reimbursements and increased claim denials
Insurers have reduced reimbursements for medical care over the last few years. They do this primarily when denying claims that do not have the correct medical codes. With efficient medical coders, they can ascribe the right medical codes, ensure better first-pass resolution rates and accelerate cash flow.
Increased coding complexity
The rise in telehealth, hospital at home, and preventive care mean that the medical coding complexity has increased. So it’s more about requiring specialized coders to be updated with the latest guidelines.
Coding for healthcare quality measures
The concept of value-based care anchors on the ability of medical codes to define the quality of care and get incentives from federal programs.
The complexity of delivery models
Ambulatory Surgery Centers or outpatient settings are increasingly responsible for complex surgeries. Medical coders understand the complexities and the associated reimbursement rules in ASC and outpatient settings. A team of medical coding experts can help healthcare organizations with timely reimbursements and help achieve targeted quality measures.
Outsourcing and offshoring medical coding
Most businesses are outsourcing and offshoring the medical coding process to a certified firm. The quality of medical coders in offshore locations is excellent, and their work may help reduce denials, improve reimbursements, and plug revenue leakage. Healthcare providers and revenue cycle aggregators must choose the right service provider when improving the coding quality. It’s more about achieving market-leading outcomes. Here are the benefits when outsourcing and offshoring RCM processes,
Scalability and access to experienced coders
The growing demand for medical coding requires access to a large pool of coders with experience in inpatient, outpatient, emergency department, and risk adjustment coding. In addition, offshoring gives access to the labor pool.
Enabling doctors to focus on patient care
Doctors share the responsibility for clinical documentation and coding with medical coders. Therefore, top-performing medical coding staff can reduce the administrative burden on doctors.
Coding quality
High-quality medical coding ensures that the first-pass resolution of claims is higher and leads to accelerated cash flow realization. In addition, experienced medical coders can plug revenue leakage when you identify discharges, not final billed cases, and reduce revenue leakage.
Improved physician satisfaction
Seasoned medical coders help enhance clinical documentation. This leads to improved physician satisfaction rather than addressing individual claims for clinical documentation issues. They aggregate issues by physicians and facilities to create scalable clinical documentation improvement programs.
Cost efficiency
Offering medical coding programs reduces clinical coding by over 40-50%.
Leveling up the revenue cycle
There can be trouble when keeping up with claims. A/R days quickly add up. However, there are solutions for these. Also, the back-end functions of a business office are complex, and here’s how businesses share a few tips to make it more manageable.
Claims submission
- Submission of new claims every day to avoid timely filing denials.
- Put a process in place to identify coding or charge entry mistakes before mistakes before claims get sent to decrease avoidable denials.
- Dedicated team to train staff to familiarize them with the claims process and edits.
Payment posting
- Automation minimizes errors and leads to accurate payment posting and overall profitability.
- You need to note individual line details when posting adjustments and denials to make follow-up more efficient.
- You need to ensure that there are no errors with the direct payment, which could further lead to any secondary or tertiary payers filing claims with mistakes.
Credit balances and refund processing
- Work credits and issues regularly refund to prevent them when it comes to accumulating. Refunds need to be issued within 60 days to prevent confusion and hassle.
- Consider system automation to apply patient credits to other services where appropriate and cut down on staff time needed to identify credit balances.
Denial resolution and underpayment analysis
- Separate claims into preventable denials and those that need to be managed upon occurrence.
- Determine if there’s missing or inaccurate information leading to denials
- Load fees schedules to automatically identify any variance by payers
Customer service and patient pay
You need to establish productive contact points to meet the patient’s unique needs. A revenue cycle management company uses data to determine which patients can pay without multiple contact points to save time and resources.
You need to set consistent expectations and benchmarks for patient-facing staff. Training the patient representatives is the first step in a positive patient experience. You must be transparent about goals and regularly check in to ensure the staff feels supported.
Final Wrap
A checklist with tactics for improving the revenue cycle performance. There are tactics you can take action. Others can be entrusted to a revenue cycle partner. Healthcare organizations need to supplement their medical coding resources by adopting the best practices for shifting focus from denial management to denial prevention.
Medical debt collection agencies must include trained staff members. An efficient verification process reduces the likelihood of denials and further accelerates the cash flow cycle. We’re a team of experts as we address coding denials and accelerate the adoption of best practices for shifting focus from denial management to prevention.
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