Coding Abuse: Avoiding Enforcement Actions With Common Sense Protections
Submitting “clean” claims is something we emphasize here on the blog all the time – mostly in the context of ensuring forms and fields are filled out clearly for processing. But there’s another factor that makes a claim “clean,” too: Its legality.
Fraudulent claims are in the government’s crosshairs. The U.S. Department of Justice (DOJ) enforces the False Claims Act, Anti-Kickback Statute, and other laws by cracking down on coding abuse – taking aim at improperly used modifiers, overcharged services, unnecessary equipment, and so on.
That means that upcoding and downcoding can destroy your practice – and if your staff isn’t diligent about cross-checking code use, fraudulent activities on your team could pass undetected until it’s too late. Sniff out problematic coding practices on your team with these tips.
Implementing a New Medical Practice Solution? 3 Keys to Success
Has your organization decided to swap out your existing software stack for a smarter toolset? Congratulations – reaching consensus for a new solution is no easy feat (and often takes far longer than providers expect).
Regardless, deciding to switch is only the beginning of the solution implementation process. Your new vendor will undoubtedly help guide you through the experience – ideally, with the added guidance and expertise of your medical billing service. But even with the best consultative help out there, many practices still miss gaps in their approach internally.
Creating a strong sense of expectations and plans can keep your whole team engaged and on-goal throughout the implementation process. Here are our top three pieces of advice as you start putting a selected solution into action.
What Type of Medical Billing Firm Do You Need?
When they’ve never used a medical billing firm before, doctors and practice managers can be hesitant to outsource revenue cycle management. Often, it’s an issue of perception.
When billing operations are managed entirely in-house, leaders tend to believe that the practice has stronger “control” over its cash flow (even if their poor metrics prove otherwise). By outsourcing, the thinking goes, aren’t they just handing the reins over to someone else?
5 Best Practices for Boosting Clean Claim Ratios
Your practice’s ‘clean claim’ ratio is the average number of claims paid on first submission. How’s yours?
Every provider would love to reach a percentage above 95%, but it’s not really the number that matters. Practice budgets are tight, and your staff’s time is the most precious resource you have. So if your clean claims rate is less than 85% (or worse), it means your staff is likely spending lots of time on identifying denial reasons, coordinating with payers, and re-submitting claims.
That’s far from ideal. To make smarter use of resources around your practice, embrace these best practices that can help you get paid on first-submit more frequently.
How Can Private Patient Advocates Help Providers' Performance?
It was 2007 when US News first called private patient advocacy an “ahead-of-the-curve” career path serving a “huge unmet need.” More than a decade later, the role private patient advocates play in the US healthcare system is still growing – and the unmet need remains.
Private patient advocates are hired by individuals to help navigate the landscape of care. These professionals give patients an ally on their side – someone capable of applying healthcare expertise to cut through the complexities of treatment coordination and billing to help patients make fully informed decisions.
Using Tech to Improve Patient Access & Practice Efficiency
When it comes to technology, healthcare providers may feel they have their hands full meeting the requirements of incentive programs. Beyond ensuring their solutions are able to report on MIPS and MACRA and meet Meaningful Use expectations, what else is there?
Well, practices and hospitals certainly aren’t required to upgrade too much else. But failing to do so might have a damaging impact on their long-term health. As the reimbursement environment grows more value-based and consumer-driven, providers will need to more than the bare minimum with their technology.
Adhering to incentive-program expectations is only the beginning – especially because it focuses mainly on the reportability of your data, and the operability of your internal systems. Consumers, quite frankly, don’t care about that.
Tips on Making Prior Authorizations a Smaller Part of Your Day
Prior authorizations are one of the most time-consuming, onerous aspects of the fee-for-service healthcare system. Just as doctors: AMA research shows that 84% of physicians consider the burden of prior authorizations as high or extremely high.
How to Keep Cash Payments From Tripping Up Your Practice
Accepting cash payments is one way practices can broaden their revenue beyond traditional fee-for-service. For our readers in integrative health fields – such as acupuncture, massage therapy or chiropractic practice – accepting cash payments is typically a necessity (like it or not) given the challenges of insurer plans.
Still, cash-pay acceptance can create a unique set of issues for practices to deal with. And that’s true whether the need is motivated by an “actual cash” problem (that is, a need to accept full payment from patients who do not have health insurance) or an “effective cash” problem (in which insurance doesn’t cover desired services, or deductibles have yet to be met).
A few best practices can help providers handle both kinds of cash-pay concerns with confidence.
Pursuing the Right Software Set-Up to Get Your Practice Paid Quickly
Reaching the outcomes you want, in all walks of life, requires using the right tools. But in the medical practice environment, it can be hard to know if your solutions are hindering your success.
When it comes to practice management and medical billing technology, providers have a tendency to settle for systems that are “good enough” to get the job done. But doctors and their teams deserve better… and when they use better tools, they see better results.
Relying on modern, integrated solutions (as opposed to outdated, hardware-bound systems) can minimize unnecessary denials and rejections, because the best tools streamline complex onboarding processes and provide guardrails to help you submit clean claims.
Negotiating with Payers for Better Reimbursements: 3 Tips
Small practices often feel like they have no leverage with payers. But while it’s true that large practices have a lot more power at the negotiating table, independent providers should always make sure their reimbursements are paid fairly – at rates that respect the quality of care delivered.