The healthcare industry is a unique
business that is different from other businesses as it deals with not a single
transaction but a procedure starting from the appointment of a patient with the
physician and ending with the patient’s account closure. Managing a healthcare
facility is a tremendous task which includes vital matters like insurance
verification, medical coding, medical billing and collections. Let us take a
look at some of the challenges faced by the medical billing industry.
Claim rejections: According to
recent studies more than 20% of claims submitted are rejected. And more than a
quarter of these rejected claims are not submitted again. If we think about the
reasons for claim rejections, we can find two major answers: claims are not
received by the insurance payer; insurance payer denies the claims. Usually,
the payer denies the claims when there is a defect in the claim with respect to
incomplete information or lack of support for the bills.
Denials not re-appealed: It is found
that more than half of the denied claims are not re-appealed. Usually, denials
are a result of administrative errors and it is a costly and time-consuming
affair for a healthcare facility to do the follow-up and re-appeal for payment.
Amount spent on non-core medical
matters: Because of old traditional methods followed by insurance payers, most
of the transactions involving payers result in a huge amount being spent on
non-core medical activities like medical
billing, claims processing and revenue cycle management.
Health insurers’ errors: It is a
major concern for healthcare facilities that there is around 20% error rate
among health insurance providers which shows their inefficiency at handling
insurance claims and results in billions of losses for healthcare providers.
MACRA final rule: In the very
near future MACRA is to be implemented and healthcare facilities should comply
with the new MACRA requirements. For this physicians should report every
patient’s treatment via a certified electronic health record to get paid for
their services or else they will lose on the payment. Also, healthcare
facilities should opt for either alternative payment methods (APMs) or merit-based
incentive payment system (MIPS). Along
with these, ensuring that all the procedures are coded as per ICD-10 and billed
properly is also required.
Bad physician documentation: Many
times medical billers are not responsible for the highest level of coding as
they do not get appropriate and accurate physician documentation. So, providers
should give accurate information to the coders so that billers can properly
bill for each and every procedure without undercoding.
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