We are in an era of complex healthcare billing that can cost providers lost revenue due to lack of knowledge and proper training. Without these much needed tools, providers are faced with significant loss of revenue for their company. The good news is many of these mistakes are avoidable with proper checks and balances in place. Noted below are a few fundamental areas to pay special attention…

VERIFICATION OF BENEFITS 

Accurate, upfront verification validation is a crucial step to avoid any future denials and loss of revenue before services have been rendered. Proper training and knowledge of the most vital questions to ask when validating covered services on insurance policy plans is the first necessary component (i.e., does the member have Out-Of-Network benefits or does the member plan include behavioral health benefits, etc.?). 

Keep in mind that you rely on the representatives from the carriers to provide precise and accurate data. Furthermore, unless you have the knowledge to identify inaccurate information being provided, the chance of you receiving invalid information at times may be significant. 

It is also just as important to begin to have familiarity with the most common payers that you accept so that you may be able to have a knowledge base of the reimbursement pattern. 

UTILIZATION REVIEW 

Another vital component in this industry is the utilization review process; which encompasses obtaining authorization for proposed dates of service. This is a stringent, meticulous process that compares requests for medical services to actual treatment guidelines set by various carriers. This process also sets the tone for the recommended direction of treatment. Obtaining authorization will essentially ensure that the services are deemed medically necessary and are in fact payable, which will also minimize loss in revenue. As a result, documentation is a key aspect, clinical documentation must be accurate and important information must be documented accurately.  

BILLING & COLLECTIONS   

Submitting claims with inappropriate coding is another major pitfall that providers are faced with. It is essential to have staff experienced with coding knowledge when billing to carriers to avoid upfront denials or decrease in reimbursement. Researching each carrier’s requirements will also help to assist in claims submission, but be mindful that their requirements can change frequently, so it is important to stay abreast of the changes when applied. 

The most common pitfall is having inexperienced collectors that do not have a strong background in the area of specialty. It is imperative to have a team with the specialty skillset to handle claim denials and appeals in a timely fashion for reconsideration so that monies will not be left uncollected.

With that being said, it is crucial to have a strong internal and/or external team with the knowledge base of handling all aspects of your revenue cycle management needs to ensure maximum reimbursement for ongoing growth. 

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