Medical Billing, Charge Capture and Code Validation
Realtime coding alerts help avoid errors and maximize reimbursement
In today’s complex environment of medical coding and billing, only an automated method of claim validation can help avoid downstream denials, delayed payments, and help prevent payer rejections. PracticeSuite’s all-payer NCCI Edits solution continuously updates so your claims get validated properly prior to submission for faster more accurate claims processing and quicker payments. Here are 8 sure fire ways to optimize your medical billing.
Accurate rules validation prevents overpayments and underpayments and speeds up your overall time to payment resulting in better accuracy in revenue projection for more predictable cash flow that allows for better operational insight helping your clinical, financial, and administrative areas work together more efficiently.
An once of prevention: Code correction during the billing process eliminates the future need to hunt down rejection causes, or contact payers, or submit appeals, or monitor endless payer rules.
Benefits are Great and Many
Coding edits we maintain:
Note: CMS alone has over 14,000 edits in its National Correct Coding Initiative that update quarterly, while other payers may publish coding changes at any time. Only an automated solution can insure accurate claims and quick payments.
What are claim edits?
- Governmental, Medicare, and compliance guidelines outlining how an insurance claim must be coded for it to be successfully processed by the payer
How does claim editing work?
- The “edits” or rules are built into the practice management and billing system you utilize for claim submission, and prior to a claim being sent out to the payer, the claim is scrubbed to ensure the proper coding compliance
- Examples of Edits
- CCI (Correct Coding Initiative) Edit:
- The purpose of a CCI edit is to help prevent unnecessary payment when an incorrect combination of codes are reported on a claim. These are based on medical coding standards, which includes a list of code pairs which are not meant to be on a claim together for many reasons: for example, two or more procedures that are impossible to be performed in the same session.
- Ex: an Ophthalmologist cannot order a Scanning Computerized Ophthalmic Diagnostic Imaging on the for glaucoma, during the same day as ordering an Optical Coherence Tomography for retina – the procedures are mutually exclusive.
- MUE (Medical Necessity) Edit:
- The purpose of a MUE edit is to ensure a reduction in error rates on paid claims. This can refer to the units of service that can be reported for a single date of service.
- Ex: Not more than two cataract surgeries can be performed, since each person only has two eyes.
- Gender Edits:
- The purpose of the gender edits is to ensure that procedures are aligned to the patient’s anatomy
- Ex: Cannot bill for a pregnancy procedure on a male patient
What are the benefits and value behind implementing claim edits within your Practice Management platform?
- Significant reduction in the rate of denials when it comes to your billed claims
- Increasing your clean claim rate, also known as a first past submission rate. Practices leveraging claim edits reliably experience a clean claim rate between 94% and 98%
- Increase your speed to revenue and reduce days in AR. Rejections are instantly identified for you to correct, prior to being submitted to the clearinghouse
- This can save you an average of 24 days of waiting time for rejections to come back from the clearinghouse or from the payer
What is Medical Billing?
If Cashflow is the Life Blood of Your Practice
Medical Billing and Coding Are Its Heartbeat
Accurate charge capture can impact 75% of a typical practice’s revenue. A finely tuned billing department is no accident and neither are accurately codded medical claims. The key to understanding the difference between medical coding and medical billing is that coding is concerned with capturing the precise level of specificity for a clinical procedure or service, while billing is concerned with speeding up payments and the revenue cycle by understanding payer rules and avoiding rejections and denials to get paid faster. The difference is accuracy vs speed. Without accuracy the need for speed is a distant concern.
But every astute billing manager knows that avoiding denials begins way back at the beginning with a well organized front office, efficient workflows, clearly articulated policies and procedures, and the systematic enforcement of best practices.
And the number one best practice in medical billing is for front office staff to check eligibility and verify benefits to establish what’s covered by insurance and what is the patient’s responsibility.
The secret to optimizing your entire “patient-to-pay” process is office automation software which streamlines each step in the medical billing continuum adding checks and balances to create efficiency and insure tight financial controls.
Cash flow really is the lifeblood of your medical practice. So if patient collections are off or receivables are high, profitability is headed downward.
Here are the seven levers, or areas of practice management that are key to improving cash flow in your practice:
- Educating Personnel
- Utilizing Technology
- Using a Clearinghouse
- Monitoring Rejections
- Managing Denials
- Monitoring A/R for Accurate Insurance and Patient Payments
- Utilizing Metrics to Measure Productivity
Step 1 : Organize Your Front Office
When you bundle the best techniques of successful practices into one easy-to-use practice management software platform, you gain control of your patient payments, claims billing, and receivables. Here’s how:
Front Office Tasks
Scheduling: Everything begins with the patient appointment. Here is a detailed process flow chart of a typical patient visit. Quality control is a key factor in each event.
1) Patient Management
a) Pre-visit: Verify benefits.
b) Estimate patient responsibility (Patient Consult)
c) Obtain prior authorizations
2) Staff Scheduling
a) Personnel scheduling
i) Multi-location scheduling needs
b) Equipment and Resource scheduling
a) Print forms
b) Print labels, schedules, and charge-slips (superbills).
4) Patient Check-in
i) Recheck benefits
ii) Pull charts
b) Intake Forms:
i) Medical history
ii) Family history
iii) Prescription history
iv) Personal habits history (smoke, drink, etc.)
5) Patient Payments & Cash Mgmt
6) Pre-Exam: Vitals. Chief Complaint. Enter Hx history into EHR.
a) Upgrade status to: Ready for physician/exam.
With flexible appointment scheduling software, you can easily find next available time-slots, schedule resources, and print patient’s visits. Appointment reminders help eliminate costly missed appointments.
All Scheduling Features
Eligibility & Authorizations
Verifying health benefits before the arrival of the patient is essential not only to the revenue cycle but to patient care as well. Real-time eligibility can be checked instantly at the point of care or automatically each night in batch. Electronic authorizations are available through Emdeon and RelayHealth. You can review the patients complete eligibility verification history. And each detailed reports shows active coverage, copay, annual deductible & Co-insurance for various type of services.
Upon arrival, good software insures a smooth office flow, but it also insures that patient pay is collected along with any open balances. Advanced office software can help improve patient wait-times by alerting doctors to waiting patients and keeping staff abreast of a patient status at all times.
Robust and Powerful Appointment Reporting
- Appointment Schedule Report
- Appointment Worksheet Report
- Appointment Status Report
- Appointment – End of Day Reconciliation Sheet Report
- Missed/Cancelled Appointments Report
- Patient Examination Summary Report
- Eligible Visits Bill Report
Optimize Appointment Scheduling
Everything starts when the phone rings and the patient requests an appointment. Organizing and optimizing your practice with a powerful and flexible patient scheduler that provides integrated eligibility, appointment reminders, patient engagement is the second step to finetuning your medical practice.
Here are a few scheduler highlights!
- Simple and easy Scheduler interface
- Color Code Appointment by Status
- Predefined Appointment time slots: e.g. 30 Minutes for new patient, 15 minutes for follow-up, etc
- Built-in Eligibility Verification
- Single click option to view weekly or daily schedule
- Search patient appointments instantly
- Multiple appointments on the same time slot
- Keep multiple appointment screens open while you navigate to other areas of the application
- Easy to set follow-up and recurring appointments
- Ability to generate forms, superbills, patient labels or patient demographics from scheduler
- Instant access to patient financial summary
- Instant access to patient ledger, statements etc from scheduler.
- Block single, multiple or recurring appointment time slots for a specific Provider
- Block single, multiple or recurring appointment time slots for the whole Practice/Entity
- Customize appointments by name for multi-providers practices with supervising physician
- Schedule Resources/First Available
- Find Patients Instantly
- User Definable Time Slots
- Unlimited Color Coding Options
- Multiple View
- Appointment Scheduling Report
- Auto generate custom Missed / Cancelled Appointment Letter
- Generate Superbills
- Auto generate custom Recall Letter
- Comprehensive Patient Demographics
- Label Generator
- Self-learning Appointment Reasons
- User Defined Status and Status Coloring
- Easy click Follow-up and multiple recurring
- Capture Surgery and other notes per appointment
Large Facility Enterprise Features
- Multiple Locations
- Multiple Tax Ids
- Resources and Equipment
- Comprehensive Patient ledger
- Track: Changes, and Cancellation
- View Appointment Hx
- Print future appointments
- Enter Insurance Details
- Customizable Superbills per Provider
- View Patient Balance & Co-pays
- Track Cancelled & Missed Appointments
- Track Changed Appointments
- Track Superbills
- Enter Co-pays and Payments from Calendar
- Print Receipts
- Track missing Co-pays
- Extensive Notes per Patient Visit
- Double, Triple Appointment booking
- Set Recurring Appointments
- Add Unlimited Providers to Scheduler
- Easy Maneuvering Between Providers and locations
- Search for Open Time Slots
- Adjust Time Slot for Individual Appointments
- Missed Copay Report
- Missing Superbill Report
Practice PortalThe role of a patient portal in appointment scheduling is to allow patient to schedule pre-designated time slots online and avoid tying up staff time and phone lines. In the back end billing process it is to notify patients of balances and provide an easy way to make payments, thus avoiding collections and unpaid balances.
- Custom Website Content
- Online Scheduling
- Online Availability
- Online Medical Records
- Credit card processing
- End of Day Reconciliation of Front Office Payments
- User Audit Trial
- Remote user access restriction
lnstant Insurance Eligibility Verification
- Connects with 1300+ payers including Medicare and many state payers
- Instant Eligibility History
- View Copay, coverage and other vital insurance information
Best Practice #3
How To Optimize Patient Check-In in Your Medical Office or Clinic
With PracticeSuite’s powerfulFront Office Kiosk, patients can enter their medical history, family history, allergies, insurances, and chief complaint (reason for the visit) from the comfort of their home. Upon arrival, they can thenSelf Check-inusing our Front Desk Patient KIOSK.
Patient Status Include:
- Arrival Time
- Check-in Time
- Vitals & Room Status
- Ready for Exam – Physician Notified
- Labs, Orders, Recalls
- Referral Station
- Check-out, Payments
- Departure time
Optimizing Patient Care and EHR
Clinical Care ManagementThe role of EHR in the billing process is critical as all medical coding depends on and is taken from the clinical note. When you try our EHR, you’ll find yourself thinking how charting could be so easy and so natural. As simple as charting on paper, our entire clinical workbench is laid out on a single screen that is easily navigated on a Tablet, iPad, Desktop, or Notebook. In fact the entire patient record is on one single screen and is designed to let you chart using voice recognition, a stylus, a keyboard, or all of the above. Affordable and proven to work for General Medicine and +61 medical specialties, PracticeSuite’s simple and intuitive EHR allows you to document encounters in seconds with a unique Single Screen Design that gives the the look and feel of paper charting; and you can easily customize encounter sheets and forms to tailored to your needs. Where appropriate, you can quickly copy the patient’s last note, modify, and save it in seconds. Most importantly, billers have instant access to patient notes for medical coding.
The Clinical Encounter Process8) Exam/Review of Systems a) Record (chart) findings b) Orders (Rx, Labs/Rad, Drug Interactions & Formularies). c) Referrals. d) Consultation Sheets. Document mgmt. Growth Charts e) E&M coding assistance f) e-Superbill: Auto-creates charges on hold for review 9) Task Assignment: Inter-office Communication. Team coordination of care
Scan and Store Documents Within the Patient Record:
- Incoming faxes create an automatic ticket and PDF attachment
- Sent emails or faxes automatically create a ticket
- Create links with super-bills, images, and other documents to reference scanned documents
- Assign tickets to staff to monitor, communicate with client, or other staff
- Maintains a complete step-by-step audit trail
- Monitor open tickets and effectively manage office workload
- ICD-10 Operational: Select familiar ICD-9 codes and learn ICD-10 while you chart
- Perfect for Tablets, PC’s, Laptops, Android, Apple, iPad, Safari, and Mac.
- Easy to learn and adopt. Encounter sheets are easy to customize.
- Document multi-condition, multi-problem visit without the use of restrictive templates
- Use voice recognition, a keyboard, stylus, or a mouse.
- Single screen design allows access to entire patient record without changing screen
- E&M Coding. Clinical Decision Support (CDSS). Quality Reporting (PQRS). Computerized Order Entry (CPOE).
- ONC-ATCB Certified Stage 2 Complete EHR
- To-do list, Inter-office and intra-office communication (communication between locations).
- Electronic Superbill that’s completely integrated with appointment scheduling and billing
Optimizing Prescribing, Ordering, email and faxing
Prescribe, Order, FaxYou can quickly review formularies, pharmacy locations, order, and fax all from within the patient record with little or no bouncing from screen to screen.
CommunicatePracticeSuite billing and EHR software has a powerful Inter-office communications module that allows you to assign tasks to any user in your practice – across multiple offices and locations, and set reminders and alerts to keep your tasks on track. Save a medical record as “For Review” and assign it to another doctor to add their notes, and when the note is complete, save it as “Complete”.
Order, e-Prescribe, eFax, Email
- Transmit electronic prescriptions to +70,000 pharmacies (Surescripts)
- Receive electronic lab results from most national labs: Quest, Lab Corp, etc.
- Fax within the patient record with integrated e-Faxing
- Email within the patient record with secure email
- Push lab results, referrals, and any other communications to a patient’s Patient Portal account
Best Practice #6
Optimizing The Revenue Cycle
With PracticeSuite, your practice can instantly achieve a 94% first-pass claims success rate. We accomplish this through a combination of Front-End Edits that ensure that every claim is payer-ready before it’s sent. Our system also automatically checks eligibility. And while verifying eligibility is no guarantee that a claim will get paid, it ensures that the patient’s treatment is covered by their benefits and that your appeal for medical necessity will have a far higher chance of success.
Classic Back Office Functions
10) Check-out: Collect patient balances.
a) Referral Desk. Recalls
11) Post Check-out:
a) Finalize and create insurance charges
i) Clinical notes avail in Charge Entry screen
In modern software, medical claims are often created in a semi-automated way from data taken from the physician’s clinical notes, and are then passed through a claim validation and scrubbing engine that checks the charges against local and regional payer rates, CCI edits and CMS edits. They then go to a medical biller for spot review, hand edit, and charge approval.
Approved claims are then batched and transmitted securely to an clearinghouse (EDI) for secure transmission to the health insurance payer. At which point they are watched closely for rejection due to errors on the claim, payment delays, or payer denials.
12) PM & EDI: Integrated Clearinghouse functionality
a) Secure claim transmission to payer
i) 11 claim status codes
13) Posting insurance payments and patient payments.
a) Secondary insurance claims
i) Adjustments & Write-offs
ii) Insurance balances visible in appointment calender
14) Patient Balances / Pre-Collections
a) Soft collection letters.
b) Patient balances displayed in patient ledger and appointment scheduler
a) In-house vs Outsourced.
Managing Collections, Rejections and Denials
The surest way to minimize A/R is by collecting as high a percentage of revenue upfront as possible by collecting patient-pay, and making sure the patient’s benefits were checked and authorizations were obtained prior to treatment to reduce claim rejections and denials. Keeping open patient balances at a minimum and appealing denials quickly and persistently helps keep receivables low.
With PracticeSuite Claims Management software, you can accelerate the collections process with customizable work queues, automated insurance collections ticklers, and comprehensive tracking tools. Efficiently follow-up on denials and non-response claim rejections with our easy option for single or bulk resubmit. All necessary information for claims follow-up is available on a single screen.
- Reduce your outstanding A/R days
- Improve billing efficiency
- Reduce billing cost
- Improve cash flow
- Get paid in a timely fashion
- Faster reimbursement
- Integrated claims correction and online reference tools
- Centralized financial reporting
- Reduce redundant data entry
- ERA and auto posting
- Claims submission and tracking
- Denied claims management
Real-time Revenue Monitoring
- Patients are checked-in but eligibility is unchecked
- Co-pays / patient pay are uncollected
- Appointments are deleted, canceled, moved, missed, etc.
- An unauthorized visit or procedure is about to happen
- Patients have been seen but remain unbilled
- Balances above your preset threshold are written off
- Timely filing presets are ignored
- Claims or denials are not followed up
- Collections performance is below preset threshold
- We monitor User productivity, and offer User productivity reporting
- ERA auto-posts denials and under payments
- For manual EOB/payment, enter $0 payments with 5010 compliant denial codes
- Run Denial Reports
- Denials get posted to collectors in Collections/Follow-up workbench
- Complete end-to-end workflow to track follow-up and collections activities
- Run Reimbursement Analysis Report to compare under payments against contract schedule
- Small balances can be written-off or adjusted through Mass Adjustment Module with custom defined or pre-defined adjustment codes
Installments/Payment Plan Management
- Easily schedule patient payment plans
- Easy access to View/Print payment plan activities
- Easy access to print letters to patient on payment plan screen
- Patients on Payment Plan are excluded from statements cycle
- List / View all Patients added to the Payment Plan
- Print/View payment plan details
- Generate Statements using robust and flexible criteria
- Unique identifier for each statement
- Easy access to snapshots of each statement
- Complete Statement History with details
- Print patient friendly statements
- Customizable downloadable format for third-party printing
- Easy access to statement history
- Print statement from Scheduler & Patient Ledger
- Easy access to Last Statement Date and Last Payment date from Ledger
- Print Statement by Guarantor (Individual/Entity)
- Search and Post Patient Payments by Statement #number
- Complete audit trail of statements: View, Export and Print
- Multiple print formats to choose from
- Ability to transfer patients to Pre-Collection status
- Ability to generate Pre-collections Letters
- Pre-Collection patients are excluded from statements cycle
- Easy access to view and print patients in Pre-Collections status
- Downloadable format for third-party printing
- Configure alerts easily
Write Off Management
- Predefined and custom defined write-off types
- Standard contractual v/s other write offs are entered and tracked separately
- Write-offs at line level for granular tracking
- Write-off reporting (Detailed and Summary)
- Capitated HMO claims are written-off automatically after successful submission
Measure PerformanceA robust and granular reporting system provides you with sharper insight into your revenue and cash flow; Advanced Revenue Cycle Management software helps eliminate missing information, incorrect codes, data entry errors, and everything else that can result in rejected or denied claims. A complete system for managing every step of the reimbursement cycle, our software offers a 94% first-pass claims success rate to ensure faster and accurate payments.
Best Practice #8
Billing, Claims and Practice Reporting
1) Multi-Dimensional Reporting
a) Each department: Financial. Clinical. Productivity. Patient Satisfaction.
Management reports are probably the most crucial aspect of a Practice Management system. But like all systems, ‘garbage-in’ means ‘garbage out’. So the data entered into your billing system must be precise and strictly controlled to achieve the end-result information required to manage the practice.
PracticeSuite has over 100 Billing Reports; each downloadable to Excel for easy slicing and dicing of data.
In order to achieve optimum office efficiency and maximum revenue, great practice management software needs to automate workflow, record cash events, organize and monitor processes, and generate crucial management reports. Exceptional billing software will allow you to:
- Offer multiple ways to identify or look-up patients
- Secure and encrypted cards on file (with consent)
- Create flexible payment plans that track date, and amount, of the last payment.
- Report any unapplied monies
- Create customized letters to payers, work-comp, attorneys, and patients
- Monitor and control write downs
- Coding: Creating charges
- Reviewing Charges: why Claim Scrubbing is so important
- Managing Claim Rejections
- Denial & Appeals
- Posting Payments and adjustments
- ERA: Electronic Remittance Advice (electronic E.O.B.)
- Claim Performance Dashboard
- UB04 Billing
- Managing Patient Portions
- Credit Card Management (with consent)
- Patient Statement Batches
- Electronic Patient Statements
- Benchmark Reporting of key performance indicators