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Whether you’re a primary care physician, a specialist, or an integrative provider, navigating insurance billing is often not only an administrative hassle, but if not done well, it can also be an impediment to growing your revenue and practice. In fact, data shows that almost 15+% of claims are denied, resulting in millions of dollars in lost revenue for providers. This trend in denied claims is also increasing in the last few years, with denial rates increasing by almost 17% since 2019. Thus, it is important to take control of your billing process. Here at Soundry Health, we provide billing services and process thousands of claims on behalf of practitioners. Below are some of the most common mistakes and tips we’ve found across the revenue cycle that providers should consider.
Tina Hsiao, MBA
- Correct data entry and demographics at check-in: This seems elementary but surprisingly many practices don’t properly train their front desk about the importance of this first, crucial part of the billing cycle. Accurate data entry during patient check-in is critical. Gathering complete insurance and demographic information helps ensure proper billing and reduces potential claim denials. Make sure that you always collect a photo of the patient’s insurance card, and most importantly, get a photo of the back of the card. The back of the card is often more important for billing than the front.
- Understanding your insurance payer contracts: Familiarize yourself with the terms of your insurance payer contracts. Knowing exactly what your contract allows in terms of reimbursement rates, covered services, and billing guidelines helps prevent underpayment or denials. Many times providers will bill for treatments that their license allows but which that particular insurance payer’s contract does not actually allow.
- Accurate coding of symptoms vs. diagnoses: Use the appropriate diagnosis codes for billing, avoiding the use of symptoms as primary codes. Insurance companies typically require specific diagnoses for proper reimbursement. Primary care providers or their billers often make the mistake of coding for the symptom vs. the underlying diagnosis. Take for example, a patient who comes in seeking help for a sore throat. If the diagnosis is streptococcal pharyngitis, then the coding needs to be for streptococcal pharyngitis (bacterial or acute) in order for the insurance payer to accept the claim.
- Frequent and proactive denials management: Actively follow up on denied claims and address the issues promptly. Letting accounts receivable (AR) build up can lead to financial complications and decreased revenue. Analyzing denial patterns, rectifying errors, and resubmitting claims correctly are essential steps. In particular, don’t leave denial follow ups to biweekly or monthly batched processes. The best practice is to build denials into your standard, weekly claims, and payment posting processes. In addition, the first time you receive a denial, your billing team should call the insurance payer to understand the reason behind the denial. This way, you can prevent the same error from occurring in future claims.
- Thorough documentation: Maintain detailed and accurate medical records for each patient. Poor documentation not only affects patient care but can also lead to audit risks and billing disputes. Even if you have not yet been audited, there is always a risk that you will be in the future. And of course, proper documentation is not only required under your insurance payer contract but also required as a part of your state license as a health care practitioner.
- Proper secondary insurance filing: Understand the proper procedures for filing claims with secondary insurance providers. Make sure you know the coordination of benefits (COB) and which insurance is the primary one. Claims can get stuck in COB where both insurances are claiming they aren’t primary. Often, the patient may not even be entirely clear as to which is the primary. In those cases, it is important that the patient contacts their insurance payers and verifies the primary vs. secondary insurance. Furthermore, secondary payers often require physical documentation of the primary rejecting the claim first and this physical explanation of benefits documentation must be mailed along with the claim. A patient with access to multiple insurance plans is ultimately a benefit to the patient and provider but does require extra work to properly file claims.
- Medicare billing compliance: Follow the guidelines set by Medicare's Local Coverage Determinations (LCDs) when billing for services. Noncompliance could lead to denied claims and financial penalties. Make sure you know what kind of Medicare provider you are: par, non-par or non-participating. If you are a Medicare provider, make sure that you know and have access to your provider transaction number (PTAN). It is notoriously difficult to get through to Medicare without your PTAN and it is equally difficult trying to determine your number if you did not make note of it when you received your Medicare welcome letter.
- Access to insurance portals: Ensure you have access to the online portals of all insurance providers you work with. This will help you track claims, check eligibility, and communicate efficiently. Most importantly, as the practice owner, always make sure you retain administrative access to the portals. It is appropriate and necessary to give access to these portals to your billing and front desk teams. However, make sure to quickly deactivate any terminated employees.
The implementation of these billing tips can be a transformative step towards improving the financial health of your primary care practice. Beyond reducing billing errors, these strategies can also enhance the overall patient experience. As you integrate these practices into your operations, you're not just managing bills; you're laying the groundwork for the growth and success of your practice. In a landscape where every aspect of health care is interconnected, mastering the art of billing becomes not just a necessity, but a strategic advantage.
Tina Hsiao, MBA, is the chief operating officer of Soundry Health, an innovative EHR and billing platform. Prior to joining Soundry, she was chief operating officer of WePay, an innovative payments company that was acquired by JPMorgan Chase & Co. She also scaled and launched several businesses at Intuit and QuickBooks.