At a Glance
- New regulations and payer challenges, such as tighter Medicaid controls and scrutiny of E&M codes, have emerged post-COVID-19 pandemic, complicating medical billing.
- Reducing claim denials relies on clear initial paperwork, precise coding, and proactive patient insurance verification.
- For 2024, success hinges on assembling skilled teams, offering targeted training, and employing digital tools to enhance billing efficiency and revenue.
Getting paid enables practices and billing companies to grow faster — but capturing payments hasn’t been easy since the start of the COVID-19 pandemic. However, there are several ways to improve the billing process and drive revenue.
In our recent webinar, Aimee Heckman, a healthcare business consultant with over 35 years of experience in medical practice management, offers insights into the medical billing industry and strategies to optimize payments in 2024.
We’ve summarized the highlights below.
State of the healthcare industry
Learn about crucial 2024 updates to the industry, and regulatory and payer challenges to be aware of.
New regulatory challenges
The public health emergency technically ended in May 2023 but continues to affect the healthcare industry, particularly when dealing with billing. Key regulatory challenges and changes include:
- Tighter Medicaid controls. The COVID-19 pandemic led many organizations to relax requirements and normal controls, leading to this overpayment. However, we are already seeing a return to tighter controls to reduce overpayments.
- More Health Insurance Portability and Accountability Act (HIPAA) data breaches. In 2022 and 2023, millions of patients suffered from data breaches. Unfortunately, social media and news outlets were often involved in these breaches.
- Medicare’s 2024 final fee schedule. This expanded options for medicare patients to access mental health professionals. Primary care providers can also leverage a new add-on code, G2211, for compensation related to patients with complex and multiple comorbidities.
- Restriction of medical debt information. The Consumer Financial Protection Bureau (CFPB) is an independent government agency that protects the American consumer from unfair business practices. In 2022, it proposed excluding medical debt to calculate vantage scores, making it difficult to collect from patients.
Payer challenges
Payers also face significant hurdles when it comes to making payments:
- Evaluation and management (E&M) code denials. Patients attending procedures without a separately identified NM service for a condition not related to a procedure face almost automatic denials.
- Stringent ICD-10 coding requirements. Including diagnosing codes irrelevant to a patient visit leads to additional claim denials.
- Increasing smart edits. Smart edits is a claim optimization tool meant to reduce rejections. However, it can confuse practice management systems and cause errors.
The “end” of the public health emergency
The end of the COVID-19 public health emergency has driven many of the regulatory changes over the past 2 years. Verified telehealth benefits have reduced the use of patient cost-sharing. Despite its flexibility for providers and patients, there have been adjustments to cross-state treatments that may affect billing.
Overcoming payer roadblocks
Medical billers and practices now face additional challenges in ensuring claim acceptances. These rejections stem from several sources. But there are ways to reduce the likelihood of rejection and streamline your claims process.
Reducing rejections and denials starts at the front desk
Many rejections stem from unclear or confusing paperwork.
For example, filing claims covered by more than one health plan, known as coordinating benefits, can result in rejected claims and delayed payment due to overlapping policies and confusion over which plan pays first. Asking patients to contact their insurance to discuss a denial during their next appointment can reduce confusion and speed up the process.
“Simple data entry errors are the major cause of rejections. ”
Furthermore, ensuring patients regularly update their payer forms at their PCP can streamline the billing process while decreasing paperwork hiccups.
“Simple data entry errors are the major cause of rejections,” says Aimee. “It’s important that your staff are the first point of contact. You can also use digital forms offerings to allow patients to enter their own information.”
65% of rejected claims will never be resubmitted, and it's harder and more costly to resubmit than it is to get it right the first time. So, follow the steps to ensure that claims are good from the start.
Payer proofing your coding
Many E&M codes and code modifiers have come under increased scrutiny for potential misuse, including modifier 25, which represents a significant and separate E&M service by the same physician on the same day of a procedure or appointment. Ensuring that the use of modifier 25 matches guidelines and maintaining code documentation can increase the likelihood of claim acceptance. Only include codes on the claim that relates to the patient’s visit.
“If it wasn't addressed during the visit, and it's not documented, don't include the code on your claim,” says Aimee.
Documenting visits to beat automatic denials
Avoid notes that look like copy-and-paste descriptions from earlier notes, also called carry forward notes, to reduce automatic claim denials. Furthermore, ensure the documentation includes specific information from the most recent visit and that the codes match the conditions addressed.
“If you do use carry forward, clear out anything that wasn’t addressed during the visit,” says Aimee. “More importantly, ensure you add information on what was addressed.”
Preparing for a strong 2024: Lessons from successful practices and billing companies
In 2024, there are many strategies that billing companies and medical practices can use to improve their billing process and get paid on time.
Build a successful team
Finding the right people is only step one in developing a successful team. Proper onboarding, perks, and policy documentation improve staff retention and empower your staff.
Providing resources, training, and strategic recommendations
Often, medical billers have to spend valuable time correcting avoidable errors when practices aren’t doing their part. In a recent Tebra survey:
- 57% of medical billing companies said practices fail to verify insurance is up to date and eligible
- 37% of medical billing companies said practices submit inaccurate patient information
- 37% of medical billing companies said practices don't get prior authorizations
In addition, 52% of billing companies are prioritizing training their own staff over training their practices, despite the fact that the most common frustrations and roadblocks are coming from mistakes on the practice side. Frustrations like the ones above can drain time and internal resources, so practices and billing companies need to invest in proper training for both internal and client staff.
Capture every dollar you can
Accurate coding and charge capture not only keep pace with regulations but also reduce the likelihood of rejections, improve cash flow, and boost revenue.
Don’t let dollars walk out the door
There are many easy-to-implement ways practices can provide value while capturing more revenue.
Streamlining check-in with digital patient tools, such as an online booking calendar or portal, removes pressure from the front desk and patients while reducing no-shows. Digital intake forms reduce data entry errors and help you collect better co-pays. Additional payment or statement options make it even easier to collect.
Year-end housekeeping
The key to preventing billing errors and claim denials is preparation. Medical billers and practice management can drive growth while staying compliant by:
- Conducting HIPAA risk assessments
- Applying for MIPS/QPP exceptions
- Reviewing the cost-sharing reset and benefits verification
- Refreshing eligibility verification policies
Get all the details
Want more than the highlights? Check out our full webinar with Aimee Heckmann and learn how to optimize your billing in 2024.
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