For primary care practices, earning enough revenue to meet overhead expenses and provide quality care has always been a challenge. But practices often make the challenge even greater through sloppy coding and billing, leading to delayed or incorrect reimbursements from payers.
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For primary care practices, earning enough revenue to meet overhead expenses and provide quality care has always been a challenge. But practices often make the challenge even greater through sloppy coding and billing, leading to delayed or incorrect reimbursements from payers. The Centers for Medicare & Medicaid Services estimates that in fiscal year 2021, Medicare made $6.25 billion in fee-for-service payments that were improper under its coverage, coding and billing rules.
Fortunately, there are steps doctors and practice administrators can take to ensure they receive all they are owed in a timely fashion. But it requires forethought, training, and commitment from everyone in the practice.
Identify the most common reasons for denials and how to handle them differently to improve practice revenue.
Audit your practice’s coding program and identify areas for improvement.
Learn coding best practices and what changes may be in store.
MEET THE PANELIST
Nancy M. Enos, FACMPE, CPMA
MGMA Health Care Consulting Group
didn’t go to medical school to become a medical coder or biller” is a common refrain among doctors unhappy with the time and resources those tasks require. Nevertheless, coding and billing are inescapable parts of practicing medicine, and doing them poorly can have severe financial consequences, either from frequent claims denials or overbillings that the practice must then repay.
Longtime coding consultant Nancy Enos, FACMPE, CPC, CPMA, says claims denials often are the result of errors in billing. Consequently, reducing denials requires identifying the source of the mistakes and providing feedback to staff on how to avoid them. “Without that feedback loop there’s no education and no stemming the tide,” she says.
Enos advises practices to focus on three areas for reducing billing errors and claims denials: front office, clinical staff and back office. Common front office-related reasons for denials include the following:
Lack of coordination of patient benefits.
Expired insurance coverage.
Expenses not covered by a patient’s insurance.
Expenses incurred prior to the patient’s coverage date.
Lack of required precertification/authorization for an expense.
“The front office is where the revenue cycle begins,” Enos says. That means staff members need to verify eligibility up front so patients know their financial responsibilities and agree to meet them.
Clinicians can minimize claims denials by making sure their notes are concise, detailed and specific, Enos says. “’Diagnosis lacking specificity is one of the biggest reasons for denials. Putting in the clinical details such as the problem’s severity and whether it’s chronic or acute will get you to the most specific diagnosis code and get your claim paid faster,” she explains.
Other problems she frequently sees in clinical notes include:
In some ways, back office staff face the biggest challenges in the effort to reduce claims denials because many of the issues they deal with are ambiguous, Enos says. She cites the example of erroneous unbundling. “It’s difficult to completely prevent it because you don’t always know which payers will pay for lesser procedures at the same time as more comprehensive ones,” she says.
Other issues back offices frequently deal with include the following:
CPT codes are inconsistent with the place of service.
The patient has reached the benefit maximum for the time period.
Claims are duplicated.
Procedure/modification combinations are incompatible.
Referral(s) are not listed on the claim.
When such mistakes occur, “it’s the back office’s responsibility to rectify them as quickly as possible, then share the feedback with the source of the errors,” Enos says.
The possibility of having to repay thousands of dollars following a payer audit is another reason for closely monitoring billing and coding procedures, Enos notes.
“Plan to be audited at some point, and don’t assume everything’s OK as long as you’re getting paid,” she advises. The best way for practices to prepare, especially individual and small group ones, is to follow the compliance program developed by the U.S. Department of Health and Human Service’s Office of Inspector General. Its recommendations include the following:
Conduct internal monitoring and periodic audits.
Implement compliance and practice standards by developing written standards and procedures.
Designate a compliance officer or contact(s) to monitor compliance efforts and enforce practice standards.
Conduct training and education on the standards and procedures.
Investigate violations or allegations of violations and disclose any incidents to the appropriate government entity.
Develop open lines of communication such as staff meetings on how to avoid erroneous or fraudulent conduct.
Enos recommends doing “benchmark” audits of five to 10 records per provider, followed by a minimum sample of 10 to 20 of the provider’s claims submissions, either retrospective or prospective. Departments or individuals of particular concern should undergo focused audits using at least 50 charts.
“Don’t look at auditing and monitoring as a form of punitive obligation, but as a way to ensure that you’re billing and coding properly,” Enos says. She says internal monitoring has the additional benefit of identifying and correcting undercoding, a problem common to most of the practices she works with.
After completing an audit, it’s critical to share the results throughout the practice. “It makes sense for a patient to see their doctor after getting an MRI, so why wouldn’t you want to provide feedback after an audit?” she says. Then she urges using the results to develop further training and education.
“Use that audit feedback to learn, to protect your practice and make sure that you’re optimizing your reimbursement and reducing your risk,” Enos says.
Solutions & takeaways