Healthcare provider’s revenue cycle is heavily reliant on insurance claims reimbursements. However, managing these claims effectively is a challenge. Specialized office procedures must be followed if practitioners expect to receive timely payments from insurance providers. Health professionals need to monitor CPT coding updates and possess a standardized claim follow-up process that is quick, affordable and efficient.
CPT Coding Updates:
Submitting claims, managing denials, reviewing coding updates and monitoring a practice’s reimbursement rates can keep a billing department busy. However, this task is made easier if clinicians are using modern EHRs and practice management systems.
Insurance claims are sometimes rejected due to improper coding submissions. There are standard code sets that health professionals must use when submitting for claims for services rendered to government and commercial payers. For CPT (current procedure terminology), the American Medical Association (AMA) creates and regularly updates these codes.
Overall, there are three categories of CPT codes:
- Category I: Physician procedure and services
- Category II: Performance management
- Category III: Emerging technologies
In addition, the AMA has established several modifiers that are intended to be used with CPT codes. These modifiers provide more detailed information about the service which were delivered at that time. For example, in 2020, the AMA made 394 CPT changes. These changes were a combination of new codes, revisions and deletions.
Some of these new changes include:
- Updates to CPT codes for healthcare services delivered through telecommunication devices. There are now six codes for recording telehealth or e-visit services.
- There is a new code for self-measured blood pressure monitoring for patients. This is helpful for patients who have difficulty accessing healthcare.
- New CPT codes were added for health and behavior assessment and intervention services. These are intended to create better coordination of interdisciplinary care for patients.
Missing or incorrect codes, or modifiers, can lead to rejected and/or denied insurance claims. Something that any medical back office would want to avoid.
Investigating Outstanding Insurance Claims:
If an excessive number of claims are rejected or denied, a medical practice’s cash flow is quickly constrained.
Medical practices and health clinics need to investigate any outstanding claims that have been outstanding for an extended amount of time. It is essential that healthcare providers make sure that all insurance claims are adjudicated and paid. Otherwise, a medical practice’s financial statements can start to suffer from processes known as revenue leakage.
For the insurance claim submission process, there are four general scenarios that can occur. These outcomes for claims are:
 Correctly paid: This is the goal of all clinics, agencies and practices. Health Professionals are paid the expected level of reimbursement for services rendered.
 Incorrectly paid: Insurance payers sometimes improperly pay a claim. The payer may have overpaid a medical provider which will require a refund or takeback. In cases of underpayment, the payer will have to correctly adjudicate the claim.
 Denied or rejected: The claim is not paid by the insurance payer due to an error. Rejected claims occur when the patient’s insurance does not cover or authorize the procedure or treatment.
 Only partial paid: This can occur when only specific line items on the claim are paid by the insurance provider. For example, incorrectly bundled services may create this type of claim response from payers.
Outcomes 2, 3 and 4 all require a medical practice’s back office to aggressively investigate these claims. Otherwise, if they are not remedied, a backlog of outstanding claims can easily lead to an excessive amount of aged accounts and write-offs.
Create a Strategy for Successful Claims Submission:
A good back-office strategy can more effectively resolve any outstanding claim issues. One such approach is to develop a strategy that is focused on insurance payers. A summary of this strategy includes:
- Understand the regional and state specific requirements for the medical specialties for which claims are submitted.
- Consistently work to develop a good relationship with each insurance payers. This is especially helpful when unforeseen problems occur.
- Back office employees should possess a level of performance and efficiency that allows them to quickly submit claims.
This workflow is made easier by the proper application of modern Healthcare information technology. An optimized workflow is made possible through the skillful use of RCM software tools and internet-based portals. Without these tools and abilities, back offices can quickly find themselves wasting time on the phone with insurance payers without ever resolving issues.
About the Author:
Advanced Billing & Consulting Services (ABCS RCM) provides experienced medical billing, credentialing and digital marketing services for a variety of healthcare providers. Their staff is friendly and experienced with the complexities of the healthcare revenue cycle management world. ABCS allows medical practices to optimize their billing and claims processing tasks, while saving money in the long run.
Contact ABCS today to learn more about their products and services.
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