Crucial aspects of RCM your Biller does not look into

Healthcare CFOs, practice administrators and physicians are held up with their usual administrative and patient care routines that they do not pay attention to the small problems in the RCM processes which results in devastating results over a period of time. These RCM problems are not only overlooked by the billers they hire, but also neglected to a point where the only option to go forward is to write off these denied and unpaid claims as bad debts. 

Let’s see in detail about the 5 major issues which are usually overlooked by billing staff:

1.Prior authorization:

All medical services and procedures do not require prior authorization. Services which are life threatening, need consent from the patient and the services which are deemed to be pre certified before they are rendered requires authorization before the services. Procedures which are considered medically necessary for the patient but have limitations in the insurance benefits coverage and the utilization of these services are exceeded, but it needs to be performed according to the patient’s conditions then a prior authorization is required to release benefits for these services. Sometimes the insurance doesn’t directly provide authorization for these services, in these cases it is advisable to send the claim for redetermination with supporting medical records. Other services which require prior authorization are for medical equipment such as optical glasses, dentures, wheelchairs etc. Obtaining prior authorization is a long and painful process. It is necessary for practice administors and CFOs to hire resources who have experience in tackling prior authorization denials will be the best fit and save time in doing more research on one particular payer’s denial.

2.Credentialing and contract negotiations:

Approximately 20% of all medical claim  denials are due credentialing and contracting. Billers are so caught up on the day to day billing tasks they forget to keep a close attention to the lapes in contracts and if any information from the practice or hospital’s side needs ro be updated. These denials cannot be corrected or appealed unless and until the change in provided credentials or contracts are not processed correctly by insurance companies. Contracting information tends to expire a few years once and filing claims for that particular expired contract can create denials for all patient claims sent to that particular payer. We have encountered hospitals and practices that have lost almost $100k because of contract renewal neglect.To keep a keen attention on this the practice can have a dedicated credentialing staff, however it may not be profitable for practices which are looking to reduce costs. For practices like. These one good option is to subscribe to credentialing automation systems. These systems are web based and accessible anywhere. The benefit of using these systems are notifications on credentialing application statuses, credentials changes updates and time duration taken by the insurance companies to update in their database.

3.Under/overpayment and recoupment:

Getting paid for claims might be a sign of progress, however there is a down side of this as well, when a practice bills services which has been paid already as in duplicate claims, paid to another provider under the same group, capitation and incorrect service performed by the rendering provider the insurance company usually pays them by mistake and then does a monthly audit where these mistakes were identified and asked for a refund. Physicians and practice administrators always question why they don’t deny the claims during the first submission itself, the reason behind it is because all electronic claims are processed through EDI and the claim adjudication system which tends to fall through the electronic edits they have. Consolidation of daily, weekly and monthly EOBs, ERAs and EFTs are key to prevent this problem.

4.Insurance letter and correspondence:

Almost all insurances issue letters or correspondence when they need additional information, these are usually provider centered problems like submitting W9, medical records (progress notes, charts, operative reports, medical history etc.) These correspondence are mailed out to the mailing address mentioned in the claim form. The time limit to submit this information is very limited ranging from 30-45 days at the max. Mailroom staff provide this information to the billers but the forget to digitize the copy of these letters and correspondence and fail to follow up. Most of these problems are reported to us way past the deadline provided by the insurance companies. We once had to appeal a surgery claim worth $80k just because the information requested was not provided in a timely manner. If the practice administrators wants to solve this problem is to scan these documents at once they’re received and upload the document in the respective encounter created for the patient on that particular date of service.

5.Patient eligibility and benefits verification:

Missing to obtain correct information from the patient puts them in a position where the benefits are unknown and whether the particular speciality is covered by the insurance plan. Creating a copy of a patient’s insurance card will allow billers to correct this information when rejected or denied by the insurance companies. The best option to verify eligibility and benefits if your patient volume is high is to automate the process. BillingParadise has developed an eligibility and benefits verification system that will verify hundreds of eligibility and benefits within a matter of minutes. It not only provides eligibility but specialty specific benefit information and limitations including patient responsibility such as copay, coinsurance and deductible. Other insurance information is also available when using this automation system.

CFOs, practice managers and physicians should know that this is not just a biller’s Or back office issue. Front office plays a vital part in keeping these problems at bay by getting appropriate information from the patient during appointments and on visits. Creating a well functioning RCM process is an objective of all healthcare organisations. Consulting with the right expertise will allow a practice to prosper over time