Health System Billing Tips to Improve RCM Performance

Medical billing is highly complex, and for health systems, it has become more challenging than ever. The healthcare systems are considered as large networks as they cover several specialties, operate in multiple states, and different care settings. As the whole system is highly complex, billing is bound to become a complicated procedure. Here, billing is not only sending claims; it is about dealing with all the payer's rules, following the right regulations and making sure that all the payments come in time. A small mistake can cost huge audits or fines.

Most of the health systems make several billing errors like missing modifiers, delayed charges, or outdated payer rules as their in-house staff don’t have the time to stay updated with the latest regulations. These mistakes turn into claim denials, compliance issues, revenue loss, and slow reimbursements. The good thing is that you can predict those mistakes with a clear process, right systems, and prevent them before any damage gets done.

This is where the requirement of a reputed health system billing company comes into the picture. These outsourced services work as the financial backbone of your health system. They stay updated with all the complex regulations so that the healthcare staff can focus on patient care instead of juggling with administrative hassles. These experts know how to streamline the prior authorization process and work with the clinic’s EHR system to protect patient data. That is how they make sure the billing errors are minimized.

Understanding the Health System Billing Errors

Some of the smallest mistakes take a huge shape in all the large health systems as they spread quickly across different departments or states. The coding errors top the list as many in-house staff use wrong or outdated codes and incorrect modifiers. But when the list of wrong codes is being used across various locations, the the same error repeats across multiple claims which create significant billing disruptions.

Then the eligibility and insurance verification errors come which cause havoc to your clinic. When the checks are incomplete, claims are submitted with wrong plans, missing coordination of benefits, and inactive coverage, which leads to claim denials.

Inaccurate charge capture is also one of the major issues in this billing process. When the departments rely on the manual entry process, there are many services provided that are not billed, or all the charges are submitted late, hence missing payer deadlines.

The prior authorization mistake gives a final nail in the coffin. The large health systems manage high patient volumes, and missing authorizations lead to claim denials, even when the care is medically necessary. Hence, over time, all the denial follow-up turns all the smaller issues into several big losses, as these claims are not appealed, reviewed or fixed.

What is the Healthcare Billing for Multi-State System?

Each U.S. state has different healthcare regulations which includes payer policies, billing codes, and necessary documentation procedures. Some of the states have very unique Medicaid plans as the commercial payers vary their rules from one single state to another state. When a health system gets expanded into a completely new state, then the in-house staff needs to follow a different set of regulations, which creates operational challenges.

The federal rules from HIPAA, OIG, and CMS also get applied, and all these regulations create a complex structure. Hence, it becomes difficult for your staff to run the whole billing process when you are concerned about penalties, facing audits, and losing revenue. Here, the need for third-party experts becomes evident.

How Can You Tackle Health System Hassles?

You need to train your in-house staff to manage revenue in several regions. These staff need to learn about implementing technology and RCM for health system to make sure no claim denial occurs. However, if you want to avoid operational complexity, you can take the help of an outsourced health system billing company in that matter.

System Configuration and Local Rule Mapping

The billing companies use all the advanced billing software to map rules by payer and state. These systems apply the correct rules automatically. For instance, the claim submitted in New York will have a different check than in Texas. Hence, these software prevents all the mistakes before the claim is sent. That is how this rule mapping significantly saves time and reduces denials.

Making the Audit-Ready Documentation

Improper documentation is one of the major reasons for the audit process. You need to know how to document each and every service, procedure and diagnosis to stay away from claim denials. You need to constantly train them using the EHR templates to enter the important details correctly. These templates are highly essential to create a proper documentation procedure, and the outsourced health system billing services are experts in this process.

Payer Communication and State-Specific Plan Expertise

Medicaid is considered a major part of the multi-state complexity in billing. Each of these states has its own Medicaid program. These include specific requirements for prior authorization, eligibility, and documentation. Hence, you constantly need to communicate with the relevant payers to get proper reimbursement. Moreover, proper audits and appeals are important to make sure that each and every facility has the correct backup for every claim.

Partnering with an Outsourced Health System Billing Company

These third-party services tackle several front-end tasks like health system eligibility verification and prior authorization which can reduce claim denials. Their expertise also increases your collection rate by 80% and has around 97% first-pass health system accounts receivable collection rate. These companies also provide dedicated account managers and have no binding contracts.

These offshore personnel also know how to work with Epic Systems, athenahealth, eClinicalWorks, NextGen Healthcare and many other EHR software. Each of them tackles 50-55 patient’s demographic entry and can handle a high volume of prior authorization requests daily. This is how they reduce the clinic’s operational costs by 80%. So, if you take the help of in-house experts for all these tasks, then it will become highly costly for you. That is why most clinics prefer outsourcing a reputed health system billing company in that matter.

So, do you want to train your in-house staff and still audit all their work or just leave everything to the outsourced experts? The choice is yours and remember that health system revenue cycle management is ticking.