Healthcare revenue cycle management has undergone a radical and drastic change in the last decade. From days when most patients had $20 or so as co-payments and insurance companies paid claims in full, to today, when the physician first needs to consider medical necessity before ordering a lab test – things have certainly become more complex and challenging.
Claim submission and denial management are critical components to the revenue cycle of healthcare facilities. As regulations are getting more stringent with the transition to value-based care, healthcare providers are facing an increase in claim denials. It therefore comes as a surprise that nearly one-third of clinicians are still using manual processes to manage their claim denials.
April 28, 2016 witnessed the release of the proposed rule that is intended to guide the implementation of MACRA (Medicare Access and CHIP Reauthorization Act of 2015) which aims to reward clinicians and physicians engaging in activities that support and drive positive patient outcomes. MACRA, once implemented in totality, will change the way physicians taking care of Medicare patients are paid by CMS.
Healthcare facilities across the nation have or will have to face Medicare audits at some point. Even those healthcare facilities that have done everything correctly and have never had to face an audit till date cannot be certain that it may not happen in the future. An audit could be due to a single payment or a multitude of payments – in either case,
One of the recurring problems facing healthcare facilities is incorrect coding of Evaluation and Management (E/M) Services. The recent CERT (Comprehensive Error Testing) claim review analyzed by WPS Medicare reveals that within the fifteen or more services reviewed in that sample, three E/M CPT codes had been coded incorrectly in at least 44% of the total bills raised.
One of the biggest challenges faced by healthcare practices and crucial to their very survival is medical billing and collections. A healthy revenue cycle is important to sustain the process of making patients healthy. Unfortunately, physicians are trained to manage human health rather than revenue health and this is where the challenges arise.
Billing patients for outstanding balances after receiving the portion covered by the insurance company is known as balance billing. This can happen if the insurance company gives less than the amount expected or if an episode of care is mistakenly believed to be in-network and hence expected to be covered by the insurance company. Physicians who are not bound by the in-network rate agreements and are thus classified as out-of-network physicians,
Improving clinical documentation leads to revenue gains and most healthcare facilities are now exploring this program. The main reason for getting into this program is to improve your reimbursements and that will happen with improved documentation and coding. However, it is important to set specific goals when putting together a Clinical Documentation Improvement (CDI) program for your facility.
Healthcare facilities address the health needs of people and are supposed to treat the sick under all circumstances. However, for any organization to remain viable and continue to provide services, it needs to be paid for the services provided – fully and in time. In order to receive their just dues, organizations have to work with various payers,
As per Section 6401 (a) of the Affordable Care Act, all enrolled providers and suppliers are required to revalidate their Medicare enrollment information under the new enrollment screening criteria.
The Revalidation Process
- Determine which provider is being requested to revalidate
- View the information checklist
- Revalidate using Internet-based PECOS or by completing the appropriate CMS-855 application
- Check your application status
PECOS is the most efficient way to submit your revalidation information.