Category: News

There is no doubt that the COVID-19 pandemic has changed the medical community as a whole. Where most people used to just make an appointment and show up at the office, many are now opting for telephone encounters to help prevent virus spread.

For practitioners, this is a much more convenient way to offer patient centered care. Instead of trying to see a set number of people within the walls of the office each day, doctors can now treat more patients in a much more convenient format.

Here is what you need to know about telephone encounters including what they are and why they need to be documented correctly.

What Are Telephone Encounters?

Simply put, telephone encounters are clinical exchanges that occur via telephone between providers, nurses, and patients. Telephone encounters can be very useful for numerous reasons, including:

• Increased Clinic Access: Patients who might not otherwise be able to make it into the clinic physically now have access to care.
• Reduced Unnecessary Burden on Patients: Travel time and other obstacles are now reduced or completely eliminated.
• Reduced Unnecessary Hospital Visits and/or Readmission: By having easier access to primary care physicians, less patients are physically visiting emergency medical centers.
• Improved Continuity of Care: Subsequent visits to follow up for specific conditions is much easier.
• Maximize Physician and Nurse Time: Calls usually only last a few minutes, which allows for treatment or more patients within a day.

In short, there are many reasons why a practitioner would consider adding telephone encounters to their schedule that are beneficial to the overall clinic (This article does not examine the amount pay by health plans to medical practices).

Not All Phone Calls Are Telephone Encounters

However, it is important to realize that not all phone calls are telephone encounters. Knowing the difference is important, as it can mean the difference between having bills approved by insurance companies or outright denials.
The real benchmark is whether or not the call includes information that can be communicated by non-licensed staff. This includes communication of normal results, billing inquiries, or other generic phone calls. Additionally phone consults that result in an in-person appointment less than twenty-four hours later would not be considered a telemedicine visit.

Criteria for Telephone Encounters

To ensure practitioners are using the telemedicine system appropriately, there are a few guidelines that determine whether an event is truly a telephone encounter. At least one piece of criteria must be met to be considered an eligible telephone encounter:

• Medical Decision Making: The call includes medical decision making and/or care coordination that results in the involvement of a physician, nurse, or pharmacist, such as treatment plans or changes in prescription medication.
• Substitute for In-Person Clinic Visits: To be a telephone encounter, the call must be deemed an alternative for a physical visit to the clinic.
• Refills of Medications: The call includes refills of medications that would have otherwise required an in-person clinic or emergency room visit.
• Follow-Up Visit: The conversation serves as a follow-up to a previous in-person visit.
• Educational Visit: The call or involves a form of patient education such as counseling, informed consent, or motivational interviewing.

Furthermore, it is important to note that only established patients are eligible for legitimate telephone encounters.

Documentation of Telephone Encounters

When it comes to medical billing and coding, there is a specific amount of documentation that needs to be done correctly. All telephone encounters should be documented to the medical record in the same manner as an in-person clinic visit. A few of the most common documentation requirements include:

• Notation of Initiation: It should be well documented that the patient, parent, or guardian initiates the phone call.
• Notation of Consent: Documentation that the patient consents to the telephone call.
• Notation of Reason: Include notes on the reason or chief complaint requiring the telephone call.
• Medical History: Document relevant medical history, background, and/or results for the patient.
• Assessment: The practitioner’s assessment of the patient with full and detailed notes.
• Treatment Plan: The provider’s plan for treatment of the patient, including all relevant medications or other instructions.

It is also important to include detailed information to show the medical necessity on the total time spent with the patient. While it might be tempting for some patients to discuss their grandchildren’s soccer game or some other personal topic, this filler conversation should not be included in the documentation.

Wrap Up: Protecting Your Practice During Telephone Encounters

It continues to look like telephone encounters are going to stay popular long after the COVID-19 pandemic fades. That is why it is so important to learn these guidelines now and apply them within your practice. Failure to do so can lead to denials and delay of payment, which nobody wants to deal with. Instead, train your team now to help make the billing and coding process easier in the future.

Over the last few years in particular, insurance plans with high deductibles have become very popular – which means that patients are responsible for larger percentages of their own healthcare costs than ever before.

At the same time, many people are under the (unfortunately mistaken) impression than unpaid medical bills in a credit report will NOT cause any damage to their credit score over the long-term – meaning that they may not feel the urgency to pay in some situations.

Thankfully, improving patient collection in your practice to this point is not nearly as difficult as you may be fearing. You just have to take a few key steps today that will pay huge dividends (both figuratively and literally) tomorrow.

Improving Patient Collection: Steps to Take Before the Patient Appointment

After a patient books an appointment but before that day actually arrives, you should always verify all insurance information on-hand to make sure that the patient in question has the appropriate coverage. At a bare minimum, check to see that they have a deductible and if the answer to that is yes, ensure that the deductible has been met. There is software out there that can help your medical practice and your staff members do this automatically, all so that you can save a great deal of time in the process.

Likewise, have someone reach out to and communicate with the patient if there is any copay or deductible (or past due balance) before the appointment. Make sure they understand the situation and do what you can to help them take care of it in a sympathetic way, all before their appointment happens.

What to Do During a Patient’s Appointment

Once the patient’s appointment day is here, try to collect their copay, deductible or past due balance before the patient sees the provider (if possible). It is natural to meet a bit of resistance to that point, so be sure to frame your communications in a way that puts their mind at ease.
For example: rather than asking patients if they want to pay today, ask them HOW they want to pay today. Let them know about any special payment arrangements that they can make and generally just make sure that they understand all of the various options available to them.

Likewise, make sure that someone in your office can actually accept a credit card to facilitate the payment (if applicable). Really, what you are doing is trying to take care of potential issues now to create the most hassle-free payment experience possible for people. Not only will this help take care of any perceived issues with this appointment, but the positive experience will also help make people more inclined to pay again in the future.

Billing Considerations for After the Appointment and Beyond

It goes without saying that, at times, you may not be able to collect patient medical bills before or even on the day of an appointment. This is especially common these days, given the economic uncertainty brought on by the ongoing COVID-19 pandemic. Everyone has a different and unique situation, and you can never be too sure of what challenges someone may face. But at the same time, that does not mean that you do not have steps available to you after they have left your office.

First, be sure to follow up with the patient about any past due balance as soon as you can after the appointment – even as soon as the next day is okay in a lot of situations. Generally speaking, it may be more practical for medical practices to send statements to patient homes as a first option. This statement should include as much relevant information as possible including when the service was provided, what specifically was done during the service, the portion of the bill being paid by insurance, and more. If the patient receives the statement but still does not pay, that is when you will want to reach out by giving them a call.

Again, you are trying to put their mind at ease and remind them of what they are actually paying for. A lot of times people will be much more open to the idea of making this type of late payment if they understand what you are trying to collect for.

If possible, offer an option to pay bills online as this can absolutely help increase collection. Someone may not like the idea of giving a credit card number over the phone, and that’s understandable – but let them know that you have a secure online payment portal that they can take advantage of at their convenience.

Likewise, if you are able to, offer a payment plan for larger amounts to help all parties involved. Not only do patients not have to worry about suddenly coming up with a huge amount of cash at once, but you also get to collect on the bill itself – albeit in small portions. Oftentimes, this compromise can make all the difference in the world. All of this will not just improve your relationships with your patients – it will help support your revenue cycle as well.

At Symbion, we pride ourselves on acting as a partner to medical practices like yours – and one that wants to help you optimize your collection and achieve the most accurate, timely reimbursement possible. So if you’d like to find out more information about these and other simple strategies that you can use to improve patient collection in your medical practice, or if you’d just like to discuss your own needs with someone in a little more detail, please don’t delay – give us a call today at (800) 672-8149 or visit us at www.symbioncoding.com.

DOCUMENTATION TIPS

Medical record documentation of patient diagnoses that is clear, concise, and described to the highest level of specificity facilitates:

• Quality patient care with better outcomes
• Accurate diagnosis code assignment
• Appropriate and timely health care provider payment for service rendered

History versus active

• Please do not use “history” to describe a current or chronic condition that is still present
• If a condition is in remission, please describe the condition as in remission instead of using the word “history”

Consistency
Be watchful when using template that might introduce contradictory and/or conflicting information in the progress note. Many templates may default to “normal” value for review of systems (ROS) or in the physical exam which may conflict with information in the HPI or in the assessment. For example, a patient with severe major depression and PHQ-9 score of 23, but ROS states “patient denies depression” can be problematic to support the diagnosis for severe major depression.

Provide a clear picture of patient’s health status

Providers should document all conditions that impacted the patient’s care on the date of service. Also, all co-morbid conditions that currently exist should be documented and address in the plan. It is a good idea to include a specific treatment plan for each diagnosis such as status (stable, worsened, improved) medication changes, dietary recommendations, scheduling of diagnostic testing, etc.

By applying the above tips can help your practice achieve better outcomes for your patients and more accurate reimbursement for your value-risk contracts. At Symbion Coding, we believe in helping medical practices, MSO, ACO achieve accurate reimbursement. Please give us a call at (800) 672-8149 or we can meet in person at a place and time that is convenient for you.

ABOUT SYMBION CODING INC

Founded in 2015, Symbion Coding is a dynamic group of coding and HIM experts, working to create solutions to help medical practices, ACO and MSO achieve optimal risk score accuracy. We focus primarily on helping healthcare providers with value-risk contracts to achieve better financial results in today’s healthcare new payment models.

Over the past few years, there has been an alarming increase in cyberattacks targeting the healthcare system that represents one of the most pressing challenges to come along in this industry in quite some time. Between the prominence of ransomware, malware and phishing attempts that can be used to compromise protected health information (PHI), to the value of this confidential information on the black market, it’s easy to see why even smaller providers are being impacted in such large numbers.

Even something as seemingly simple as losing a mobile device (or having one stolen) is no longer a “minor inconvenience”, if that device had access to a network filled with private health information of patients. At that point, that could be a backdoor onto the network and a potential source of a cyberattack – pointing to a situation that must be addressed at all costs.

Thankfully, creating a more secure environment and safeguarding patient information is less the result of any one major move and is more about a series of smaller ones. When taken together, they offer up the best chance at making sure all private information stays that way for as long as possible.

The Reasons Why Smaller Medical Providers are More at Risk

It is absolutely true that even the largest healthcare providers are prone to experiencing a cyberattack, the number one reason why smaller medical practices are actually more at risk comes down to a lack of resources.

A lot of smaller practices simply do not have the human resources necessary to create a secure environment. They lack an IT team or even an employee with the skills needed to monitor systems and close security vulnerabilities. Even if they do, they probably do not have access to the type of financial resources they would need to replace older, vulnerable equipment with newer, more secure alternatives.

Many smaller medical practices in particular suffer from a lack of cybersecurity awareness. You cannot expect your average healthcare employee to successfully defend against a phishing email if they don’t know what one looks like in the first place.

Safeguarding the Records: What You Need to Know

Thankfully, there are a few straightforward best practices that you can follow to help make sure your own environment and network are as protected as possible moving forward. These include things such as:

• Creating a cybersecurity policy that involves the use of encryption on all mobile devices in the event that they are lost or stolen. This way, even if the physical device itself should fall into the wrong hands, that person won’t be able to access any of the information contained on it – or use it as a backdoor opportunity to infiltrate your network.
• Always make sure that both your computers and the software you install on them are updated whenever possible. Oftentimes people do not realize that software and operating system updates do more than just tweak the user interface or add new features. They patch security vulnerabilities that could potentially be exploited by someone who knows what they are doing.
• Create different Wi-Fi networks for your staff and for patients. That way, even if the patient network is compromised due to the presence of insecure devices, you do not have to worry about that spilling onto your primary practice network.

Along the same lines, you will also want to make sure that all user passwords are changed on a regular basis and that strong passwords are already used. A password manager will be a key part of this by allowing employees to free up their brain power rather than forcing them to remember a long list of passwords. Most password managers will also automatically generate stronger, non-repetitive and unpredictable passwords as well.

It is also important to use multi-factor authentication whenever possible, which requires a password and an additional input before someone can gain access to an account. This can be a PIN from a phone, some form of fingerprint verification, facial recognition, or something else. Regardless, it is far more secure than just a password alone.

At the same time, always make sure that any vendor you use to store and process information (like your coding and billing company, for example) has safety measures put in place to protect that data. No matter what steps you take, if your vendor is not secure and compliant, you are not either.

The Importance of Staff Training

Finally, understand that investing in staff training is and will always be one of the keys to staying safe in the modern era. Never forget that most data breaches happen due to social engineering – meaning that people who lack cyberattack awareness training are being taken advantage of on a regular basis.
You should hold training sessions for your employees at least once a year with a particular focus on the types of behaviors that cause violations and breaches in the first place.

Symbion Coding: A HIPAA Trusted Partner

At Symbion Coding, we are a secure and HIPAA compliant coding and billing vendor. In addition to offering a true multi-layered approach to protection that keep your PHI safe and secure at all times, we also work directly with our partners to make sure that they feel safe throughout the entire process. We sign and abide by a business associate agreement whenever we engage with a new client, which helps make sure that we always act as a true partner to your practice in every sense of the term.

If you are looking for a coding and billing vendor that is HIPAA compliant with the knowledge and expertise in revenue cycle, please give us a call at (800) 672-8249 or visit us at www.symbioncoding.com today.

If you had to make a list of some of the major pain points associated with most medical practices, resubmitting claims would undoubtedly be right at the top.

Not only does this mean that a medical practice has to wait longer periods of time to collect money that they’re owed, but you also have to consider the costs associated to rework that claim in the first place – costs that add up in a frustrating and often surprising way.

This has always been problematic, but it is an especially difficult situation to find yourself in given everything that is currently going on in the world. During a period of time when practices need to remain more productive and more competitive than ever, you cannot afford to spend so much time working and reworking claims that do not have to be this difficult. You also certainly do not want to extend your ability to get paid for the work that you have already done any longer than you absolutely have to.

Thankfully, there are a number of straightforward steps that you can take to reduce denials in your own practice and often prevent them altogether. You just have to keep a few key things in mind.

What You Need to Know to Prevent Denials: Breaking Things Down

By far, one of the most important things to do to prevent denials from happening at all involves the acknowledgement that billing absolutely begins with the front desk.

Your front desk employees need to be checking someone’s eligibility as soon as you can – ideally two to three days before an appointment. They should verify that the provided demographic information is accurate and that they have every other relevant bit of data they need to submit the claim in the first place. Likewise, you should be educating your staff members on coding and the impact of clinical documentation on the revenue cycle. The providers themselves especially need to be educated. All of these things will make a big, big impact moving forward.

In addition to taking steps to prevent denials that occur because of coding errors, you can also make use of an external person to provide the aforementioned education to your employees. Think about it like this: the costs associated with hiring that external educator are often far lower than the loss of revenue due to a provider’s lack of knowledge. Even if you go through comprehensive training sessions twice a year with a special emphasis on the most common diagnoses and procedures used in the medical practice, you could still increase your reimbursement in the long run.

Track Denials for Better Outcomes Moving Forward

Another one of the best ways to reduce denial rates in your medical practice involves coming to a better understanding of why they may be happening in the first place. Far too often, medical practices know that denials are happening, but they are not really sure why. They are certainly not aware that, more often than not, they are falling victim to the same few mistakes that are happening over and over again. If they would just make some slight adjustments to their workflows here or there, the lion’s share of their problems would be over. But some medical practice may not have the knowledge or the resources to do that, so this frustrating cycle repeats itself indefinitely.

To get to that point, you will need to determine the root causes that you are dealing with. Oftentimes, this involves issues at the front desk (like incorrect demographic information), billing errors (like CCI edits or incorrect modifiers), coding problems (like a ICD-10-CM code for female being used on a male patient) and more.

Once you have a better understanding of why those denials are occurring, be sure to share the results with providers and office staff members so that they are aware of what is going on. Implement new processes to avoid making similar mistakes and definitely continue to monitor things in the future.

Based on that, you will definitely want to conduct internal audits on a regular basis as sometimes this can be the most efficient way to find revenue cycle gaps that would have otherwise gone undiscovered. Do not be afraid to seek independent outside help if you need to or if you happen to be busy on other projects. Symbion Coding, Inc., for example, charges a reasonable fee to provide audit services that come complete with a recommendation on how to close those revenue cycle gaps once and for all.

In the end, while the above steps may be a significant amount of effort above what you are used to, you need to consider the raw value that they will bring to the table. Not only will you spend less time re-working claims that never should have been denied in the first place, but you’ll also speed up the frequency at which you get paid and increase revenue to your practice as well. All of this frees up more time in your day to focus on those matters that really need you, thus paving the way for an even more successful medical practice in the future.

If you’d like to find out even more information about how to reduce and eliminate claim denials as much as possible in your medical practice, or if you’d just like to discuss your own needs with someone in a bit more detail, please don’t delay – contact Symbion Coding, Inc. today at (800) 672-8149 or visit our website: www.symbioncoding.com

Coding errors are a significant problem in the healthcare industry. According to Healthcare Business & Technology, every year medical providers lose more than a billion dollars, and one of the primary factors is linked to billing errors due to incorrect coding. Coding errors have a severe impact on a healthcare facility’s bottom line and can have legal and financial consequences as well.

Impact of Coding Errors

Healthcare is a multi-trillion-dollar industry, yet each year healthcare providers struggle due to poor billing practices directly related to coding errors. Underpayment, overpayment, and legal exposure are common consequences associated with billing errors. Here are some ways incorrect billing can have an impact.

• Underpayment means the healthcare provider is one of those collectively losing about $125 billion per year per Healthcare Business & Technology.
• Overpayment can be considered a false claim and, if deemed to be the case and/or the coding errors are consistent, it can be deemed as fraud and treated as such.
• Healthcare providers who are wrongly paid for their services can face legal consequences under the False Claims Act.

To avoid these costly problems, it is important medical facilities and provider’s offices correctly enter the codes associated with a patient’s diagnosis and procedure. For this to happen, underlying causes must be identified. These can be linked to a number of things, such as the coder, provider documentation, computer systems, or even an institutional problem.

Coder Lacks Knowledge or Experience

If the person doing the coding does not have sufficient clinical knowledge of disease process, knowledge of coding convention, and application of coding guidelines and coding advice, this could potentially lead to errors in the billing process being made. Ineffective work habits, such as selecting ICD-10 from the index instead of the tabular list, is another root cause.

A healthcare provider can avoid many of these problems by hiring certified medical billing coders. This doesn’t necessarily solve all problems but will go a long way towards ensuring correct codes are entered since professionals should possess strong knowledge about the process and with experience, they should be able to identify any red flags made by other underlying causes associated with errors.

Provider’s Documentation Contains Problems

Providers often inadvertently contribute to medical billing errors. For instance, if they provide the coder with incomplete or conflicting documentation, this can result in the billing person entering the wrong codes into the system. Late documentation by the provider or non-specific documentation are also common contributors to wrongful billing. Upcoding is another problem. For instance, if the provider meets with the patient for a few minutes to do a med check, but bills for a full hour physical exam, this could potentially create a compliance risk for the medical practice. A competent biller can help avoid many of these problems associated with provider documentation because he or she will notice the documentation does not support the level of visit selected by the provider.

Computer Systems are Outdated

Technology has emerged to be a major disruptor in the healthcare industry. It is important for healthcare facilities and providers to ensure their software is up to date. If billing personnel are using older computer software not equipped to accommodate current coding requirements, this can results in problems. For instance, outdated codes in computer systems being used to generate bills will result in incorrect billing and code descriptions will not necessarily match the official code descriptions of ICD-10 codes, CPT, and HCPCS. Additionally, a faulty interface between clinical and billing systems may result in codes not correctly transferring from coding to billing.
Many healthcare providers and facilities turn to third-party billing vendors because of their expertise and the fact they use updated technology. Hospitals, doctors’ offices, and other medical facilities know they are covered from a technology standpoint and they do not have to absorb the cost of upgraded technology themselves.

Institutional Standards are Not Up to Par

Sometimes the root cause of billing errors is linked to institutional policies and practices. For example, if there is an absence of accountability processes, medical staff may be slacking in completing progress notes in a timely manner and providing accurate and complete documentation. Other issues may be a lack of coding quality or regular coding education and training for all staff. These can all lead to colossal billing mistakes.

According to the website Baby Boomers, 30% – 80% of medical bills contain errors. However, connecting with expert certified coders can significantly mitigate the problems associated with coding errors and reduce the number of returned claims or duplicate billing. They understand the fundamentals associated with medical coding and are up to date on the changes occurring in a consistently changing healthcare landscape. In short, they will be diligent and help ensure you are paid correctly, and organizations do not inadvertently break any healthcare laws, ultimately saving both time and money.

Providers who want to avoid coding errors should ensure an up-to-date system is used for billing, policies and procedures are in place for the medical and coding and billing staff, and provider education is offered on a regular basis.

Sources

https://www.ama-assn.org/practice-management/cpt/8-medical-coding-mistakes-could-cost-you
https://www.beckershospitalreview.com/finance/medical-billing-errors-growing-says-medical-billing-advocates-of-america.html
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review
https://mticollege.edu/blog/healthcare/medical-billing-and-coding-professional/common-errors-in-medical-billing-and-coding-and-how-to-avoid-them/
https://www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm
https://news.unchealthcare.org/icd10/icd10/content/what-is-icd-10
https://www.physicianspractice.com/view/five-common-coding-errors-medical-practices
https://www.healthitoutcomes.com/doc/the-impact-of-technology-on-medical-billing-and-coding-0001

There are many benefits to working in the healthcare field. Not only do you get to ensure people in your community live their best and healthiest lives, but you get to be a support system during some of the most challenging times they will ever encounter.

However, that extra level of trust your patients put into your practice also comes with a large dose of liability. To help protect the business and your reputation, it is a good idea to have certain safeguards in place when it comes to billing. Here is what you need to know about having a medical coding compliance program.

Why Is It Important to Have a Coding Compliance Program?

There are numerous reasons why your medical practice should have this type of program in place.

For starters, there can easily be a high error rate in claims submitted by staff due to things like insufficient documentation, incorrect coding, and lack of medical necessity. This is just leaving money on the table for your practice due to errors that could easily be prevented.

In addition, the government is cracking down on issues related to fraud and abuse. In fact, many government agencies are taking certain steps to combat this problem. If you bill Medicare or Medicaid, this can mean a delay in payment or even losing the ability to submit claims. Examples include:

• Increased number of prepayment reviewed
• Increased post payment reviewed
• Overpayment recovery

Having a coding compliance program in place can help protect your income and keep issues like these from happening. In fact, it is a good idea for every medical practice and not just major healthcare providers like hospitals or surgical centers.

What Should Be Included in a Coding Compliance Program?

Now that you know you need a medical coding compliance program in your healthcare clinic, it is important to discuss what you need to include. This list certainly is not comprehensive, as only you and your administrators know what is most beneficial to your practice. However, it is a good rule of thumb to include all or most of the following in your plan.

Written Policy and Procedures

You need to have some form of written policies and procedures for your medical billing department. This guide should, at a minimum, include things like internal coding practices and minimum documentation requirements for progress notes.

Also consider plans for technological issues. If computer software is used for coding, there should be a section on what to do when a coding error is detected. For example, your medical billing software might have instances where an ICD-10 code does not match the service description. What should your staff do in this instance?

By keeping everyone on the same page, you can ensure that mistakes are caught immediately before bigger issues arise.

Education

One way to reduce and minimize coding errors is to have a written plan for employee education. The overall policy should include the type of education and/or certification expected for anyone in a coding position within your clinic or practice and these standards should be adhered to as close as possible.

There should also include a section that requires coders to complete continuing education units. And when you do host coding education in-service sessions, keep thorough records of all types of training (both internal and external) with notes on who was trained, what they were trained on, and the exact dates of the training.

Auditing to Monitor Results

Finally, your medical coding compliance program needs some form of auditing to monitor results. For example, you want to monitor coding accuracy by performing periodic audits of each coding employee’s work. You should also set an accuracy standard for the medical practice to ensure everyone is meeting that benchmark.
If this seems like it would be too tedious or your practice is small, you might consider hiring an external auditing company. These firms look at your files, let you know where there are errors, and provide you with written reports. Select a firm who can do a totally unbiased audit with no incentive to maximize reimbursement for errors caught.

Disciplinary Action

Now that you know that you need an audit component to your medical coding compliance program, it is also important to consider having a disciplinary action plan. Why? If you notice a coding employee is continually making errors or a bigger situation occurs, you need to know how you want to proceed and when it is time to make a staffing replacement.

Understand that human nature is to make small errors, but if the auditing program continually finds big issues, there needs to be a set action plan in place. Only you will know what works best for your clinic and staff, but examples include intervention, probationary periods, warnings, and even ultimately firing.

Likewise, you need to have a correctional action plan when employees make mistakes and need some form of disciplinary action. Decide how long coding staff should be held to whatever action you have decided on or how you will provide training to keep the issue from happening again.

Wrap Up: Why Your Healthcare Clinic Needs a Compliance Program

Medical coding compliance programs are important, but they are only as effective as your staff makes them. By putting everything into writing and following procedures exactly, you can help reduce errors, save money, and minimize the risk of payment delays or repayments from happening.

Every year healthcare providers collectively lose approximately $125 billion due to poor billing practices (Healthcare Business &Technology). Problems associated with these losses include billing errors and a failure to stay up-to-date on the latest rules and regulations associated with medical billing.

To reduce these issues many doctors, hospitals, and other healthcare providers look to third-party partners for their medical billing needs to increase chances insurance companies will accept claims. Selecting a company to provide medical billing services is a decision not to take lightly. Healthcare providers should be prepared to understand several different aspects of third-party billing before partnering with a vendor.

Costs and fee structures

One of the primary factors healthcare providers should look at when selecting a medical billing vendor is cost because exploring billing options many find there is no one-size-fits-all solution. When making a decision, healthcare providers will want to factor in the number of claims they need to be processed, the size of their practice’s facility/office, and if their practice operates in different states. Questions to consider asking potential vendors include:

• Does the company charge set-up fees? If so, how much?
• What amount does the company charge for annual administrative fees?
• Is a flat fee, percentage of money collected, or an hourly fee the more feasible payment structure?

The last question is essential, it’s important to understand the difference.

Percentage of money collected can result in more claims being paid because these vendors tend to be more aggressive. In other words, if the practice doesn’t get paid, they don’t get paid. The drawback for small and medium-sized practices is they can lose a lot of their profits with this type of fee structure.

A flat fee structure means the medical billing company gets a set amount per claim (averaging $4-$6 per claim) which means they’ll be more inclined to pay attention to all claims, no matter how small (Medical Billing Services Review). However, denied claims aren’t always aggressively pursued since the vendor is paid either way.

Healthcare providers with small offices might find an hourly fee structure to be the best option. Essentially, the billing company gets paid for actual hours worked. This is similar to an in-house billing specialist, but without the salary and benefit responsibilities employers are obligated to pay.

What is included in billing services?

Service providers can offer accurate medical coding, filing claims, determining insurance eligibility, posting payments, following up on denied claims, following up with patients, and sound advice on better claim filing processes.

• Compile a detailed list of exactly what’s included (and not included) in the contract.
• Determine what gaps the practice needs to be filled, and what capabilities and resources the vendor can offer.
• Ask what type of transparency in the billing cycle the vendor offers.

Many healthcare providers immediately look to the bottom line when selecting a vendor. This is a critical mistake. Billing companies charging noticeably lower prices than their competitors likely won’t provide the same quality or level of services. This can lead to problematic issues down the road.

Education and certification of employees

Partnering with a medical billing vendor should alleviate the hardships associated with billing. However, for that to happen, it’s important to determine if the vendor’s employees are educated and certified to perform vital tasks.

• Most people who work in this field typically have completed a 2-year associate’s degree or a 1-year certification program.
• Certification is voluntary, but many vendors will seek out employees who have been certified as it only strengthens their services. The most common certifications to look for Certified Coding Assistant (CCA), Certified Professional Coder (CPC), and Certified Coding Specialist (CCS). The latter is for senior coding specialists).
• Several other specialized areas of medical billing are available for workers to become certified in.

Taking a look at education and certification often provide health providers with a sense of confidence when choosing a vendor. Ideally, healthcare providers are best-served by partnering with a company with expertise in their particular practice area of medical specialty.

Measures put in place to safeguard data

Data breaches are serious, especially in an industry such as healthcare, where there are legal and financial repercussions for any mishandling or mismanagement of data that puts patients at risk for identity or financial theft. It’s imperative for all healthcare service providers to be well-versed in HIPAA and safe practices when it comes to handling patient data. This includes partners who perform billing tasks.

• Look for a partner who is willing to share what software they employ and how it is run. For instance, is it a cloud-based system in one central place, or are there several decentralized pieces involved?
• What security measures are taken to protect sensitive data in storage or in transit?
• How are passwords stored?
• What is the process for destroying records no longer needed?

The best medical billing companies put a heavy emphasis on HIPAA-compliant billing processes.

Bottom line, when selecting a vendor, don’t focus solely on price. Instead, look at the whole package for what level of services are received for fees paid. A few extra dollars may be worth the fewer headaches associated with the complexities associated with medical billing and coding.