“Due to shifts in cost sharing, a larger portion of many hospitals’ reimbursement now comes from patients rather than commercial payers. This means hospitals are interfacing more than ever with consumers to collect.” — from a Becker’s Hospital CFO report on managing patient billing complaints.
Collecting from consumers, hospital patients, can go smooth – or end up a big bottleneck in the revenue cycle. When it comes to hospital billing best practices, a lot depends on a series of measures that successful facilities are implementing. We take a look at some common challenges and how teams are taking them on and winning.
“There are best practices that need to be followed to facilitate the billing process. For example, there are coding processes and tasks that need to be streamlined to ensure practices properly code items prior to the end of the encounter, which with the aid of the vendor and their capabilities can be identified and continuously improved on,” observes Mutaz Shegewi, research director covering provider IT transformation strategies at IDC Health Insights in Medical Economics
There are also a lot of examples of common mistakes in the claims process. “One common billing mistake typically revolves around specific state/payer regulations and requirements. Rules concerning use of modifiers, unbundling and HCPCS versus CPT code selection can change depending on the payer and the ASC’s state. Another common mistake is not thoroughly verifying benefits and receiving the appropriate authorizations. A provider may anticipate performing a specific procedure, but as the surgery progresses, that CPT code could change. When this happens, it’s critical to add the new CPT code to the authorities immediately to avoid any denials and delay in payment,” observes Angela Mattioda, Vice President of revenue cycle management Services for Surgical Notes, a provider of revenue cycle services for ambulatory surgical centers.
What are some solutions to hospital billing challenges?
In a RevCycleIntelligence article on “Best Practices for Hospital Claim Denials Management”, former Spectrum Health director of patient financial services, Frank Gless “explained that a solution that integrated with the health system’s medical billing system was beneficial. Moving away from the health system’s Microsoft Access database and to a bolt-on solution allowed staff to receive electronic remittance data from payers and create reports based on the information.” According to the article, the three best practices are:
- Using data analytics to go beyond the traditional claim denials KPI
- Implementing the right claim denials management technologies
- Engaging clinical staff in claim denials management improvement to prevent denials
Becker’s Hospital Review published an article on, “4 best practices for managing patient billing complaints”. The practices were:
- Smart front-end registration to reduce errors
- Financial counseling: “Help patients understand their insurance benefits, medical costs and financial responsibility prior to scheduling a procedure”
- Employee accountability to “revenue cycle benchmarks”
- Pay attention to trending issues: “Hospital administrators should document each billing complaint patients report”
“Part of the challenge is that denials management is not just a do-one-thing-and-do-it-well issue. You have to master three core skills—recovery, prevention, and contract negotiation—to truly stomp out denials. But other initiatives have a way of taking priority, causing teams to default to focusing their efforts on revenue recovery… Only about two-thirds of denials are recoverable, but almost all (90%) of them are preventable.” — from an article by The Advisory Board, a healthcare consultancy
In the article quoted above, The Advisory Board advocates the creation of a “strong denials prevention team” as part of hospital billing best practices. Their recommended team components:
- Engage strong leaders from across multiple departments who are affected by denials
- Establish structure
- Schedule a firm monthly meeting to ensure your efforts will be ongoing
- Secure executive support. Include the CFO, COO and VP of Nursing on your team
- Prior to each meeting, circulate a report that includes the current state of denials and drills down into root causes
When Hospital Billing Best Practices Go Beyond Your Hospital
Could the solution involve data from outside your hospital gained in the wider community? A thought-provoking article in RevCycleIntelligence makes exactly this point, observing that “Claims data also is not comprehensive enough to truly identify high-risk patients, who experience medical and socioeconomic issues not listed in medical billing information.” In Camden, New Jersey, a coalition of healthcare providers was formed with the mission of providing intervention for high-risk, high-cost patients.
According to the article, Kelly Craig, the organization’s Chief Strategy and Information Officer reports that “We built out a health information exchange in our community and we were able to start feeding in admission, discharge, and transfer (ADT) feeds from those healthcare institutions that we were able to look at every day and also get a list of who had been admitted to the hospital within the last 24 hours.”
Think about how the smart use of data can help you implement hospital billing best practices. Train your people and get buy-in from high stakeholders. Use the best technology. And while you’re at it, we would be pleased to give you a demo of our Claims Management platform solutions.