Medical Billing Audit – A Way to Optimize the Billing Process

Medical billing and coding services are the foundation of any medical practice. Furthermore, if the process does not follow the most recent criteria, medical practices may face an unstable financial condition.

Thus, healthcare businesses must consider medical billing auditing to ensure efficient revenue cycle management (RCM) and minimized accounts receivable (AR).

What is the Billing Audit?

It is a procedure that aids in the identification of issue areas in clinical documentation of given services. As a result, the purpose is to address such concerns and improve the revenue cycle.

Why Medical Billing & Coding Audit?

Medical billing audit allow healthcare providers to evaluate their billing procedures, coding semantics, and claim submission strategy. As a result, it is a method of determining whether your system is running smoothly or if it requires an upgrade for enhanced performance in medical billing and coding.

Moreover, medical billing auditing also gives insights into the inconsistencies. These issues might not be a problem at the moment but can be disastrous after a while.

Save Your Medical Practice from Penalties

A government strike is possible if your medical billing and coding services do not comply with HIPAA (Health Insurance Portability and Accountability Act). They can penalize your medical practice if your billing standards are not up to par.

Thus, billing audits are critical to improving medical billing and coding standards and streamlining the financial situation.

Why are claims rejected or denied?

Medical billing audits provide a chance to enhance claim performance. And, in general, claims are declined for the following reasons.

·         Incorrect or fraudulent payment modifications

·         Patient eligibility and verification concerns

·         Incorrect documentation of healthcare operations

·         Insufficient medical information

Many more factors may cause government or commercial insurance payers to decline the claim. And, if the potential flaws are corrected, the following results are possible.

·         The Benefits of Quality Medical Billing Audits

·         Improved coding accuracy in accordance with the most recent guidelines

·         Identification of potentially harmful errors

·         Improved billing system dependability and transparency

·         Your medical practice's optimized workflow

·         Improved collaboration between medical practices and insurance firms

These are just a few typical examples of how internal and external audits might aid in revenue cycle improvement.

Professional Billing Audit Upgrade System

We cannot overstate the importance of risk analysis in the billing and coding process in generating income. Auditing helps healthcare businesses by providing administrative benefits, coding efficiency, a greater claim acceptance rate, and clinical benefits.

Furthermore, improving medical billing services does not only increase income generation. It also improves quality and transparency in the following ways.

·         The claim compilation and submission procedure becomes seamless and quick with improved billing and coding processes.

·         The cost-efficiency improves because there is no need to invest effort and time in processing claims repeatedly.

·         The improved system is more dependable in terms of generating timely reimbursements, thus the workflow becomes more constant.

·         Data administration and documentation are simplified.

·         We are capable of developing data-driven medical billing and coding methods.

·         A solid system enables a proactive rather than reactive approach to medical billing and coding services (when some problem occurs).

·         The analysis report aids in strategic decision making and the improvement of the medical billing and coding process.

As a result, by removing system vulnerabilities, medical offices may stay current with the latest billing and coding trends.

Conclusion

The regulations have become increasingly stringent over time, and there is no room for unsuitable or deceptive services. Even if your medical billing and coding systems are sound, medical billing audits can help you avoid mistakes and ensure consistent revenue cycle management healthcare.

Significance of Pre-Authorization in Medical Billing and Claim Submission

Medical insurance companies frequently use the term "previous authorization." It means that, unless there is an emergency, a patient must obtain permission from the medical insurance provider before undertaking a certain medical procedure in order to be eligible for bill payment.

However, the insurance provider's decision to approve a prior authorization services is based on a number of variables, including the insurance limit, appropriateness, and medical necessity. There will be no reimbursement if you did not request prior authorization or if your insurance refused to provide you prior authorization. Contrarily, even a prior authorization that is granted does not ensure that you will receive a reimbursement from your insurance company.

What treatments/operations demand prior authorization or approval?

·         An insurance provider typically requests a prior authorization when:

·         A cheap alternative to treatment is conceivable.

·         If the patient's prior medical history makes the treatment ineffective for them.

·         If the procedure is being done for cosmetic or aesthetic reasons, it is not a treatment.

What role does prior authorization play in the approval of claims?

·         Prior Authorization is crucial for keeping the revenue cycle running smoothly.

·         Insurance companies and dentists collaborate to ensure effective financial management. Although occasionally the insurance companies detect discrepancy in invoices and want Prior Authorization to avoid paying anything extra out of pocket. As a result, it's possible that both the dentist and the patient will have to pay out of pocket.

·         Even when a claim has prior authorization, it may still be rejected. Therefore, it's crucial to comprehend the importance of prior authorization in the acceptance of claims. You must take certain actions, including the following, in order to have your claim processed:

Submitting a claim do include the unique Prior Authorization Number

Please make sure to mention the specific Prior Authorization Number when submitting a claim. There are therefore increased chances that your application will be rejected if the Prior Authorization Number is omitted.

By mentioning your Prior Authorization Number, you can simultaneously save time and money by reducing the likelihood that the claim will be denied.

Prior to treatment, obtain your authorization number

We are aware that obtaining a Prior Authorization Number prior to receiving treatment can be a lengthy process in and of itself. However, obtaining the Authorization number is also necessary. Particularly if the surgery is pricey and you don't want to pay for it out of pocket. However, in an emergency, the insurer might be a little more accommodating and pay the bills. However, before the operation in non-emergency situations, you must obtain an Authorization Number.

If only a portion of the treatment received prior approval

Patients occasionally submit claims for payment with their specific Authorization Numbers, however the claims are sometimes rejected. Ever ponder the reasons why? In most of these situations, the patients only receive consent for a single aspect of their overall treatment. Therefore, in order to use an insurance claim, the claim must be fully approved and not just partially.

Despite countless instances of meticulous work, the claim is still rejected. Approximately 80% of claims are rejected because they lack the appropriate authorization number. Please make sure to obtain the Prior Authorization Number prior to receiving treatment in order to have your medical insurance claim approved. In general, the Prior Authorization plays a big part in how smoothly your insurance claim is processed.

Are you looking to identify your short comings? Are you facing problems with your clinical operations? Then get in touch with medical practice consulting services.

How to Fix: Top Urgent Care Billing and Coding Mistakes

Urgent care facilities continue to expand rapidly as the healthcare landscape changes. Their capacity to deliver speedy, inexpensive, and effective medical care is what fuels their popularity. In actuality, the majority of urgent care centers have wait times of 30 minutes or less, and the majority of appointments are an hour or less. 

Private insurance claim lines for treatments provided in urgent care are long due to the booming demand for urgent care. Even though the urgent care industry is seeing tremendous growth, billing and coding errors could cause urgent care facilities to lose a lot of money. Making billing and coding errors might mean the difference between a center's success or failure for more than simply a few pennies.  

 

Here are the top five urgent care billing and coding errors, along with explanations of how to avoid them in the future. 

 

Ineffective front desk procedures not being fixed 

The front desk is where your healthcare revenue cycle solutions begins, and urgent care clinics frequently make the error of neglecting to implement effective financial procedures that start at their front desks. Make sure to collect co-pays at the beginning of patient visits rather than delaying this payment until the end. Prior to providing patients with new services, outstanding balances must be recovered.

 

Lack of effective front desk procedures can lead to an increase in bad debt, missed earnings, and patient accounts that go into collections. 

 

How can this be fixed? Establish front-of-the-house financing procedures for your urgent care center. Make sure the people at the front desk are properly trained in your procedures. Retrain staff employees on a regular basis to make sure everyone is current and using these procedures. 

Bad contracts already in place 

When you set up your contracts with payers, you must sign a contract with them committing them to pay your facility according to the fee schedule you agreed upon and to promote your facility as an in-network center in their network directory. It will be difficult to increase patient volume if you don't have contracts with payers because you won't be able to accept insurance.

 

Since contracts with low reimbursement rates indicate you aren't getting reimbursed too much for the services you are providing patients, negotiating lousy contracts might be almost as harmful as not having any contracts. Negotiated reimbursement rates must be reasonable and represent the entire range of services your urgent care billing center offers. 

Failure to Comply with Credentialing Requirements 

Credentialing and contracting are not the same thing, and the processes are extremely different. This is vital to grasp. Credentialing is the procedure a payer uses to confirm a provider's knowledge, experience, and credentials in order to guarantee patient safety.

 

Don't make the costly assumption that each payer's criteria are the same as each other because each payer has different credentialing needs. In order for claims to be processed properly, it is crucial to make sure that providers are authorized by payers. 

 

Lack of timing, bad organization, poor workflow, failing to maintain contact information up to date, and neglecting to check for state compliance are just a few of the credentialing issues that many medical facilities encounter when going through the procedure.

 

The easiest option to correct this error is to work with credentialing specialists who can help you understand the specific payer's credentialing requirements.  

Incorrect documentation or inadequately coded charts 

Even with a fantastic electronic medical records system for your urgent care, your EMR is only as good as the doctors that use it. Accidental under-coding might occur as a result of improper item documentation, costing the facility a lot of money.

 

In order for office visit codes to appropriately reflect what was done during the appointment, providers must also ensure that they are accurately documenting exams, histories, and MDM (Master data management) corrections inside the EMR system. 

 

It is crucial to endeavor to ensure that urgent care providers are fully informed on how to use the facility's EMR system because providers specialize in treating patients, not coding. Periodically, refresher classes could be beneficial as well. 

Missing Important Charges 

Missing out on important charges can cost your urgent care a lot of money, and insufficient documentation is frequently to blame. Patient visits can be so hectic that it's simple to overlook recording a step, especially if instructions have been given verbally. X-rays, interpreting findings, injections, blood samples, and labs are a few of the most frequently overlooked expenditures. 

 

Additionally, healthcare professionals could neglect to record prescription dosage amounts. It is important to accurately record the quantity of medications dispersed so that payer claims can reflect the appropriate charges. Poor visit documentation will cause claim submission delays or claim denials. 

 

Once more, it's beneficial to train the staff at your urgent care facility to remember to record some of the most frequently overlooked fees. Your EHR systems intelligent alerts can deliver reminders when providers are locking charts. Drugs dispensed and requested labs should be recorded so that future comparisons with claim charges can be made with ease. 

 

Making Errors Claim Form Filling 

Another significant urgent care billing and coding error you must avoid is making mistakes when filling out claims. Filling out claims can be difficult, and doing so runs the risk of them being denied if extraneous or critical material is left off. Your claim may be denied if you forget to include code modifiers or if you use the incorrect modifiers. Illegible handwriting on forms, neglecting to include a crucial modifier, or failing to make a diagnosis code as specific as it should be are examples of other coding errors. 

Methods for Improving Revenue Cycle Management

 Variable services, low revenue, rising costs, and rising regulatory costs result in catastrophic losses. Enhancing the organization's financial health is largely accomplished through revenue cycle optimization.

Why is optimizing revenue cycle necessary?

Optimization of the healthcare revenue cycle solutions is essential to regaining the organization's revenue after the dramatic impact it suffered last year. With the recent Corona epidemic in particular, the service providers were devoted to defending and saving lives from the life-threatening infectious illness while suffering significant losses. A lot of businesses saw such a decline in sales that they had to completely shut.

Most of the top financial service firms are working incredibly hard to recoup from catastrophic losses during the epidemic. There has been increased pressure on healthcare organizations to get their revenue cycle back on track as a result of COVID-19 and other recent developments and charges in the healthcare industry.

Strategies that can be adopted for revenue cycle management optimization

It is crucial to inform the patient clearly of the billing situation. The personnel must receive sufficient training about patient care and total medical costs. In order to facilitate payment, you can prevent the patient from receiving any unpleasant surprises when they receive their medical bills. Additionally, the patient must be given a detailed explanation of the anticipated medical costs before receiving any services. In some circumstances, the patient may be qualified for assistance through certain financial programmes. Understanding this information helps to reduce confusion during payment.

The majority of patients request a thorough cost breakdown, particularly when they select multiple therapies. Openness with the patient enhances communication. The financial clearance of patients is essential for a sustainable revenue cycle of a healthcare organization as daily growth in healthcare business trends.

Automated workflow: It has been really useful, particularly during these days without communication. For proper reimbursement, time-consuming processes including confirming eligibility and checking the status of claims must be completed regularly. Instead of working on such boring and straightforward chores, healthcare workers would be better off spending their time on more worthwhile projects that would benefit the business.

To enhance productivity and reduce time waste, sophisticated automated software is deployed. Examining each claim in detail might be more taxing and frustrate your personnel.

Workflow automation has aided in clearing patients well in advance of an appointment and avoiding unnecessary contacts, particularly during these pandemic times when no-contact is the norm.

Online patient payment options: It make simple and quick for patients to make their payments. The patient searches for more ways to pay quickly, such as online payment options. It is essential to improve the revenue cycle and support its continued health by making it easier for patients to access quick and straightforward payment methods.

Patients can more easily pay their medical bills on time thanks to the technology of online payment through numerous specialized apps, automatic text messages, and quick access to online payment portals. Utilizing cutting-edge integrated payment systems improves patient satisfaction and retention while accelerating the organization's revenue cycle.

Seeking the support of a reputable partner: It is a good decision for revenue cycle management optimization, even for a small healthcare firm.

Outsourcing RCM would be the ideal answer for dealing with reimbursement delays, inadequate technology, and amateur workflow. It increases internal operations' efficiency and fosters a high degree of transparency. It is crucial to choose a partner carefully who has in-depth understanding of the organization's area of expertise and who can integrate with modern technologies and support systems.

The staff is relieved to focus on value-adding services for patients while the outsourced team effectively handles the majority of the staff's administrative tasks, including medical billing, coding, and other related tasks.

Ways to Conduct Complete Medical Billing Audits

 Maintaining the accuracy and compliance of your medical billing systems depends on both internal and external audits. To be useful, they must be carried out carefully. Medical billing audits make sure that problems are identified in advance, preventing unpleasant surprises. Medical billing audit also uncover problems like fraud early on, before they may become a severe problem.

Designate a Team

One or a small group of capable individuals who are familiar with the organizational structure of the company and have the authority to obtain the required data should be in charge of conducting the audit. This group will function effectively as a task force, gathering reports, processing them, and producing their conclusions.

The audit will be completed more quickly and without interfering with ongoing business activities the smaller the team. Additionally, problems with tainted data or contradicting information are less likely to arise with fewer teams.

Create an Accountability System

A system of accountability doesn't have to be harsh; it's not meant to punish underachievers. Instead, a system of accountability provides rules for what employees and managers are and aren't accountable for. In essence, it facilitates their work.

It should be very evident throughout an audit whose position is in charge of which categories of work, and this position should be contacted whenever problems are discovered with that work. Too frequently, audit findings are not communicated to the appropriate parties, which results in recurrent errors.

Establish the necessary controls

An audit isn't simply intended to find errors; it's also intended to stop these errors from happening again. When errors are discovered during an audit, an evaluation must be conducted, and changes must be implemented.

A follow-up should be planned after recommendations have been made to confirm that the new controls have been put in place and are effectively resolving the problems that were identified. As audits go on, these controls should ideally be adjusted and improved rather than constantly adding new rules, which can result in a cumbersome and challenging rule set.

Establish criteria for improvement

Audits not only identify errors but also identify opportunities to streamline and improve current operations. Setting concrete standards for progress is one of the simplest methods to enhance your outsource medical billing processes. These benchmarks can be evaluated as internal audits go on to see if the billing system is improving as it should be.

Performance can be evaluated using accuracy, collections, and even write-off billing as measures. And keep in mind that every system has some degree of human error. While it's crucial to identify and correct these mistakes, holding staff to an unrealistic standard may have the exact opposite impact.

What a Medical Practice Experiences When It Outsources Medical Billing

 The intricate coding and working with Medicare, Medicaid, and several insurance companies, which demand nothing less than perfection, set medical operations apart from other types of businesses. This is a lot of responsibility to impose on medical professionals who are attempting to maintain their focus on helping patients while also needing to make sure their practice is profitable.

It can be beneficial here. The greatest in medical billing and revenue cycle management have joined forces with us, and between them, they have more than 100 years of experience assisting medical offices and other healthcare facilities. It pursues every last dollar so that your practice may continue to be autonomous and patient-centered. Although it can be scary to delegate invoicing to a third party, our clients immediately see the advantages of doing so.

A medical practice should outsource its medical billing, right?

Do things go as they should when you consider your medical practice's everyday operations? What does a normal day look like for you and your team? Are your patients getting the attention and care you wish to provide them? Are medical billing and collections proceeding according to schedule? Are the cash flows strong and the collections effective?

It's time to take a closer look at where things are going wrong if you answered "no" to the majority of these questions. It could also be time to think about outsourcing medical billing and collections.

When selecting a medical billing company, there are numerous things to take into account. Keep in mind that outsourcing your practice's medical billing, collections, and revenue management can solve a number of problems. The effectiveness of billing businesses in processing claims, however, varies widely. Therefore, if you choose a professional organization to handle your medical bills and other responsibilities, remember to look into things like their accuracy, expertise, and references.

Competent Individuals

The employees of the medical billing company should be up to date on all medical billing codes, particularly those related to your field of expertise, and they should have a firm grasp of Medicare and Worker's Compensation rules.

Speed and precision

In the processing of medical claims and billing, both accuracy and speed are essential. Compared to your own employees, skilled and knowledgeable medical billing businesses can file accurate claims more rapidly and will be paid more effectively.

A Follow-Up

Experienced medical billers and coders who can follow up on any outstanding or rejected claims should be employed by the medical billing company. This is where many medical practices lose a lot of money since their internal staff frequently struggles to keep up with accounts receivable and denied claims. A reputable, experienced medical billing business is able to forge special bonds with the practices they collaborate with. Verify that the business you are thinking about can offer you services that are specifically tailored to your practice's requirements.

Remains at the forefront of laws and best practices, in addition to revenue cycle management and billing technologies. We can also help you with things like:

• Verification of Eligibility

• System Integration

• Patient Access Management

• EMR/Technology Integration

• Consulting

Can a Medical Billing Company Increase Collection Rates?

A competent medical billing business may handle many billing and collections-related responsibilities for your practice, giving you and your team more time to concentrate on your patients, as you are aware if you are the manager of a medical practice consulting.

A reputable, knowledgeable medical billing company may improve your practice's efficiency and organization, decrease billing and coding mistakes, and raise employee and patient satisfaction.

Increased collection rates for your practice are another advantage of using the services of a reputable medical billing business.

AdvancedMD Medical Billing Services

 

One of the most popular EHR systems among medical practices is AdvancedMD. For more than 5 years, it has been effectively offering medical billing services to a number of medical practices on the AdvancedMD platform. On AdvancedMD, we offer a full-service billing solution. Everything will be handled by it, including claim filing and A/R follow-up, and our knowledgeable team will answer any questions patients have about billing. By utilizing the AdvancedMD system and experienced medical billing services, physician offices can drastically boost their revenue and boost productivity.

Why it is advised to use AdvancedMD for medical billing

• AdvancedMD is a user-friendly system.

• A clean claim is simple to make.

• AdvancedMD can be configured to show patients their co-pays and coinsurance amounts.

• On AdvancedMD, determining eligibility is simple.

• AdvancedMD is safe and hosted in the cloud.

• AdvancedMD produces better reports.

• AdvancedMD is less expensive than some other EHR solutions.

Our AdvancedMD billing professionals can assist you in raising revenue for your practice.

It has been working toward establishing high-value alliances founded on reliability, honesty, and quality in customer service for more than 20 years. At AdvancedMD, our billing specialists work as an extension of your staff. In actuality, this means that our team is always available by phone and ready to assist you. Since your revenue cycle is crucial to the success of your business, we take our responsibilities very seriously. Our main objective is to help you increase clinic payments.

The transparency of our revenue cycle management services is another essential component. You will be given the service you require thanks to monthly reports, frequent meetings with your billing staff, and quick responses to your queries.

Software for AdvancedMD Practice Management

You might start a new era of success with AdvancedMD products. The AdvancedMD billing software has several features that increase productivity, scheduling is only one of them. See how intelligent reporting and analytics, automatic claim cleaning, and integrated payment processing may help you save time and money.

More time can be taken back thanks to the AdvancedMD medical office software platform. Our industry-leading clinical and patient experience solutions are combined with billing software for the first time on this platform. How much time would you save if your entire practice could be run through a single database?

AdvancedMD RCM Methodology

Understands that the quicker you receive payment, the more money you will be able to make. AdvancedMD makes medical billing payment processing painless by automating time-consuming tasks and enabling you to auto-post charges with a swipe. There is no need to manually match payments to charges or to download and import ERAs. This sophisticated software, along with the knowledge of our highly skilled employees, takes care of everything for you.

Now all you need to do is assess and confirm. Our industry-leading medical billing software, AdvancedMD Billing, includes a number of features, including rapid and simple payment processing. You have access to automatic claims scrubbing, ERA processing, better scheduling, and an integrated clearinghouse. Everything is set up to help you increase revenue without going crazy.

The AdvancedMD cloud suite, the top full-featured medical software platform on the market, includes Advanced Billing. You can manage your practice in one location thanks to the fact that it is the only suite that incorporates Advanced Billing, our EHR, and patient experience capabilities into one database. Never before has success been so simple.

AdvancedMD EMR System

The employees at can take advantage of AdvancedMD EHR's capabilities, including those that are administrative and billing-related as well as those that are specialized to medical practices, thanks to our extensive expertise.

In addition to document management, e-prescriptions, and other capabilities for medical offices, AdvancedMD EHR offers a patient portal for check-ins and admissions. All of this is accessible as a mobile platform for iOS devices. Role-based access to AdvancedMD EHR, which reduces system complexity for each position and optimizes workflow, is available to nurses and doctors. In the course of the medical coding and billing process, there are options for how information is presented to in-house coders and how it is integrated with an outsource medical billing company's API.

Through a tier-based subscription access model, customers have access to AdvancedMD EHR and revenue cycle management technologies. After paying a one-time installation and training fee for AdvancedMD EHR