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Securing the Foundation: Medical Billing

by Michelle Mangino, Social Media Manager

Here at CloudView, we feature plenty of posts about Meaningful Use, ICD-10 (with the new October 2015 compliance date, we’ll be back from our hiatus soon), health care reform, and a number of other broad industry changes that impact the day-to-day operations of your practice. While we’ll continue to, we think it’s equally important to pay close attention to the basics that can help practices and medical groups build a strong foundation to better navigate these changes. Enter our new blog series, “Securing the Foundation,” which will feature detail on how athenahealth approaches patient engagement, care coordination, medical billing, and other topics that are part of any practice’s DNA.

To kick off the series, we’re starting with the topic of medical billing. This one is near and dear to our history; as you may recall, athenahealth was born from a birthing center practice that was having trouble getting paid for the care they delivered. These days, we want to make sure health care providers do well doing the right thing. Here are some elements of our medical billing service; if you’re currently not taking advantage of services like these, you may want to reevaluate your health IT vendor.

Comprehensive Revenue Cycle Process

One of the difficulties inherent in submitting medical claims efficiently and accurately is the number and complexity of steps in the process, and the frequency with which rules are added and changed. Below are a few suggested steps to take over the course of the medical claims revenue cycle:

  1. Pre-Registration – Enter patient insurance information and demographics into a practice database fully and accurately; have it double-checked to avoid problems later. Your practice management software should have an automatic eligibility check to ensure coverage before the patient visit.
  2. Benefit Verification – Confirm patient benefits, deductibles and co-pays with payer, and make sure patient understands them; confirm that the physician delivering care is on the patient’s insurance contract.
  3. Check-In – Copy the patient’s insurance card and make sure there are no changes in coverage; give the patient a copy of practice payment policies.
  4. Documentation of Services – Document patient history, symptoms, diagnosis and treatment plan in the medical record.
  5. Assignment of Codes – Assure accurate medical coding by recording the proper codes in the medical record and physician super bill; consider purchasing a CPT (Current Procedural Terminology) code set spreadsheet for each insurer to see which codes receive higher reimbursement.
  6. Check-Out – Collect patient co-pay, deductible and co-insurance (money collected in person is immediate revenue).
  7. Verify Coding – Have a professional coder verify medical coding based on clinical record, ensuring codes will be paid by insurer.

(For the full list of suggested steps, visit our Medical Coding and Claims Knowledge Hub.)

Vendors may offer various services across the revenue cycle process that include claim submission, insurance package management, electronic eligibility verification, payment posting, claim follow-up, and denial management. Your vendor should have a comprehensive service that leverages knowledge and automation across the revenue cycle to free you up from administrative tasks, while still giving you visibility and control. That way you can focus on activities to improve practice performance and increase revenue.

A Network and Team Behind You

Everyone in your practice is probably familiar with the feelings that come with having to deal with denied claims. Now imagine something very different. Imagine the knowledge gained from thousands of other practices combined with a team of experts working on your behalf, finding billing problems and fixing them before they reach your practice. When your practice’s medical billing services are on the cloud, this is exactly what happens.

Billing experts monitor these submissions and look for claim denial trends. As soon as they spot one, they fix the incorrect payer code that’s causing the trend and add a rule to the database. From this moment forward, no one on that cloud network will confront the problem again. Scale this process up by tens of thousands of rules and you get a system where you’re far more likely to get your claims paid the first time around. Plus, rules are constantly updated, so the engine gets smarter every day.

With up-to-date knowledge continuously delivered across the network you’ll spend less time working claim denials, so you can spend more time to prepare for big transitions like ICD-10 or even investigating alternative reimbursement models.

Visibility into Practice and Payer Performance

You can’t make improvements on your workflow if you don’t know how you’re performing. By choosing a vendor who is on the cloud, you’re capable of receiving real-time insight into your practice’s financial and operational performance as well as comprehensive reporting and benchmarking. That’s right. Benchmarking. Since all of the cloud network's participants (in this case, medical practices) use the same instance of software, you have opportunities to gauge and benchmark your performance against practices that are similar to yours. With that level of knowledge, you can easily monitor your revenue, efficiency, and, ultimately, make improvements before they become an issue.

Also, by being on the athenahealth cloud, you can receive visibility into how payers are performing. By analyzing data across our national, cloud-based network, which to date includes more than 55,000 health care providers, we’ve ranked commercial and government health insurers according to a series of specific measures covering financial, administrative, and transactional performance. (Learn about our 2014 PayerView Report results and find out which payer ranked #1 in overall performance.)

If you can nail down your medical billing strategy and partner with right vendor then you have a spring board to take on value-based payment, population management and identify other revenue initiatives.

What medical billing strategies have helped you secure a strong foundation for your practice or medical group?

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