Best-in-Class RCM Solutions
RCM inefficiencies can pose one of the most perplexing problems in cardiology practices today! Complex approval processes and requirements that differ by health insurance plan make claims management a challenge for even the most well-informed billing administrator. It’s not enough to rely on the status quo; groups today must be proactive in developing plans to improve operations and patient access procedures, as well as their RCM to meet the test.
With today’s focus shifting toward enhancing the patient experience and alleviating any roadblocks to collecting timely reimbursement, now is the time to consider a third-party partner to harness available technology, improve administrative workflows, scale for the inevitable fluctuations and staffing issues, and increase revenue.
Coding to Maximize Reimbursement with a Third-Party Partner
It’s imperative to accentuate the process of coding to achieve accuracy and maximize the shrinking healthcare dollar. To alleviate a cardiology practice from experiencing problems with the ongoing education- and personnel-related issues that arise with developing and maintaining a strong coding department, enlisting a third-party partner may provide an outstanding solution. A trusted outside team can absorb the workflow efficiently and code thoroughly to maximize reimbursement.
To fully capture revenue using a partner consider:
- A paramount challenge in healthcare, and specifically, cardiology, is staying up to date on coding with ICD-10-CM, CPT, and HCPCS codes through education and knowledge building. Engaging a partner with highly-training specialists shifts that responsibility to the third-party team allowing your staff and providers to focus on quality patient encounters.
- Demonstrated coding accuracy from an outside team minimizes your concern about human error and careless keying mistakes that can drastically affect reimbursements.
- Expert coders will capture commonly missed tests that are billable or treatment and diagnosis decisions that aren’t adequately documented that may have slipped through in the past, causing denials and rework later.
- From experience, highly trained coders will code to the highest degree of specificity and code to the diagnosis and not necessarily the symptom. Their coding decisions are under constant scrutiny and audited to ensure a quality coding program.
- Coders would ensure medical documentation is not only present but accurate and complete with every patient encounter.
- An expert third-party coding team would provide ongoing feedback for everyone impacted with comprehensive opportunities to improve the quality of the coding and documentation program.
Billing Efficiencies Brought by a Third-Party Partner
The most effective way to address the scalability issue that often stresses the billing function is to engage a third-party partner that can assume responsibility for executing all aspects of the billing process. Utilizing a scalable, cost-effective automated solution that manages billing complexities while meeting payer criteria ensures that accurate claims are submitted, paid quickly, and denials minimized.
By engaging an off-site team to provide billing support, these functions would seamlessly resolve behind the scenes:
- Charge Entry
- Payment Posting
- Credit Balance Resolution
- Contract Management
- Analytics (designed for financial management)
As a case in point, our billing support team, working with a large cardiology clinic in Texas with 50-60 providers, established an overall goal of claims submission within 24-72 hours of service. This allowed us to shave a full two weeks off the timeframe that was currently being used by the Clinic. First, by restructuring and streamlining the billing office workflow, and second, by educating and mobilizing the providers as active participants in their own RCM.3
Rely on AR Optimization Using Advanced Automation
Once a patient has been seen, and a claim has been coded and billed, there are inevitably denials and rejections that prolong payment if not outright stop revenue capture. These rejected claims make up the AR and must be worked individually to ascertain the problem and then collect the necessary information before resubmission.
Denials management is an oft-neglected process in many cardiology practices. Whether due to lack of time or clarity on next steps, denials management is often treated as busy work to be faced only when there is significant downtime. This leaves a considerable amount of money on the table in claims that merely need correction or clarification before being resubmitted for successful collection.
To optimize AR, utilize a third-party team using state-of-the-art AI-driven automation with proprietary recovery prediction algorithms to focus efforts on which denials are collectible so that energy is spent on the recovery of revenue and increase of early cash flow. By reducing write-offs and identifying the next best activity through automated algorithms based on payer guidelines and procedures, a cardiology group can be assured the maximum revenue is collected.
When evaluating claims management solution teams, consider their preferred automation technology. They should bring AI-driven software functions critical to achieving the long-term goal of permanently reducing revenue loss from denied claims:
- The ability to predict recovery, including forecasting the dollars potentially available and the timeline to achieve final collections. With machine learning algorithms, unpaid claims are evaluated on many available parameters, such as aging, payer, and modality.
- Access to predictive and deterministic criteria that prioritize follow-up strategy activities to maximize and focus human intelligence efforts where they can be most effective.
- Automated claim status checks matched with the most-likely cause, i.e., integrated insurance verification and eligibility data, CPT mismatch technology, and DOS and benefits check capabilities. Once the cause is identified, appropriate changes are made, and the claim is resubmitted.
- Auto-creation of required appeal letters, if necessary.
- Automated eFax capabilities, when required.
- The ability to perform a root cause analysis through operational analytics to find where mistakes originate upstream, including insurance verification, prior authorizations, or coding problems, so that processes can be reviewed and upgraded where necessary.
With the technology available today, each patient encounter can be verified, submitted, and followed up on in real-time. As reported in a recent Infinx Case Study, it’s conceivable to recognize a +15% improvement in 90+ days collections from using the AR Optimization Solution alone.4
Insurance Discovery to Improve Bad Debt and Collections
We know for sure—that throughout the healthcare spectrum, patients frequently present for care without understanding their insurance coverage or benefits. Phrases like “annual maximums,” “remaining deductible,” and “explanation of benefits” may be overwhelming to patients that are unfamiliar with insurance terms and how they are treated within the healthcare industry.
If your cardiology group has ended up with an outstanding amount that is treated as bad debt or uncollectible is often not from misrepresentation, but merely misunderstanding.
Couple that with the growth of patient consumerism and High Deductible Health Plans (HDHP) in recent years, we see a cascading problem that can only worsen with time. The key may be early intervention from a third-party partner using a cloud-based, AI-driven Insurance Discovery Solution.
When using an Insurance Discovery Solution, these accounts are processed through an automated coverage identifier package where patient demographics, insurance profiles, and benefits are verified, and undisclosed coverage identified. These uncompensated accounts can then be submitted to the appropriate insurance and revenue retrieved.