Every step of a practice’s RCM workflow can negatively impact RCM. So, providers must stay aware of common pitfalls that reduce collection efficiency. Innovative practices will turn these obstacles into areas where they have a competitive advantage.
Claim rejections and denials are a natural part of the medical billing and coding process. Medical experts say the average industry denial rate is between 5% and 10%. However, continuously receiving the same claim rejections indicates poor work procedures. Upon receiving a denial, categorize the following elements:
● Insurer: If an insurer rejects a disproportionately high number of claims, you may have a communication failure. Review the agency’s standards, focusing on the commonly denied areas. Contact the insurer to discuss what changes you can make to improve their acceptance rate.
● Service: Certain services challenge medical coders more than others. Investigate the roadblocks of this procedure that frustrate your staff. Implements consistent protocols to combat this frustration. In extreme cases, your practice may function better by removing the service.
● Reason: Some denials may stem from the same mistakes, such as failing to pre-verify patients’ eligibility or authorization. Determine whether this problem’s solution is revising your standards or more stringently upholding these standards. If the latter is true, employ regular internal audits to review staff workflow.
Deductibles’ burden rose 92% between 2011 and 2021. This trend demonstrates the increasing importance of patient payers. Practices can no longer lean on insurers to provide them with stable income. Providers must interact with consumers in a tactical, professional manner to receive as much reimbursement as possible.
These interactions are critical once a patient fails to make consistent payments. Tools like 360 analytics help staff determine which consumers need financial follow-ups. Give these patients realistic payment plan options tailored to fit their monetary situation.
A physician’s main priority during an operation is the patient’s long-term safety and health. So, he may make slight adjustments immediately before or during a procedure. This approach can undermine staff “Prior Authorization” efforts who have pre-authorized a specific operation, not the performed variation.
To avoid this problem, gather codes similar to the scheduled surgery and the respective codes before seeking pre-authorization. Request authorization for this entire group of codes If approved, physicians can make insurance-covered last-minute adjustments.
Running a modern medical practice that consistently provides high-quality care is daunting. Unfortunately, constructing a reliable billing system is comparably complex and time-consuming. Practices frequently fail to train collection staff appropriately or supply them with the necessary tools to succeed.
To combat this problem, consider hiring a professional billing service. Plutus Health has assembled the tools and knowledge to reliably secure high reimbursements. Our established set of consumers have consistently seen boosted income flow. Talk with a representative today to hear how we’ll improve your RCM.
1. Repeated denials indicate a problem in workflows or managing existing workflows.
2. Staff oftentimes fail to recognize the importance or lag the tools to perform needed patient follow-ups.
3. Physicians sometimes have to change procedures after a code receives prior authorization was received.
4. Practices may need a professional billing service to maximize RCM.
Gett Johnson has 30+ years of experience in Healthcare I.T. and RCM Professional. His skillset includes being an expert in Healthcare I.T. software and hardware solutions. He is helping health systems, hospitals, ASCs, medical offices, and healthcare organizations become financially healthy by optimizing complete RCM processes.
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