Claims Articles

Billing & Revenue Cycle Problems in Pain Management July 30, 2021

Pain Management

Maintaining a profitable practice means ensuring a healthy revenue cycle for any pain management practice. However, pain management practices still encounter hardships due to their complexities in billing and coding. It can be challenging to manage the processes when it involves stakeholders and obtaining payment relies on consistent interactions. Keeping departmental and payer communications open can help keep accurate information sorted and categorized throughout the process. The following are the most common billing and revenue cycle issues in Pain Management Practices:

  1. A manual process on claims denial management
  • Using a manual process for managing denials can slow down your cash flow. At the same time, it can still lead to more inaccuracies and errors.
  • According to Michelle Tohill, Director of Revenue Cycle Management at Bonafide Management System, healthcare providers should switch to automated systems to avoid denials. In addition, staying on top of diagnostic codes and different insurance policies can be exhausting. However, many software providers will automatically update requirements and coding procedures.
  • She also added that there are still many software providers who are constantly updating codes and requirements. In this way, your billing staff can double-check claims. Making sure they meet the demands and saving research time.
  • Furthermore, your staff needs to be aware of future happenings to get reimbursements, less time figuring things out, and detect necessary parties.
  • Automating claim denial management in medical billing can help providers identify errors before submitting claims.
  • There may still be difficulties toward submitting claims and associated labors in managing denials, stated Brendan FitzGerald, HIMSS Analytics Director of Research. Surprisingly, software providers have not automated the denial management process through a vendor-provided solution.
  • If managing denials are a lot, productivity might be slow through a manual process.
  • Denial management is still a question, whether it is outsourcing or in-house. The HIMSS study found that 44% of healthcare professionals preferred outsourcing such as revenue cycle management, clearinghouses, or EHRs, while 18% implemented an automated system in-house.
  • Medical billing teams from denial management draw data over healthcare industries and handle multiple payer rules and codes.

  1. Coding Errors

Incorrect codes will lead to deferred, denied, or half-paid claims. Pain management practices continue to struggle with the complexities of codes for pain management coding procedures. These are the top coding issues:

  • Inaccurate coding on clinical coverage
  • Improper procedural codes
  • Out-of-date codes

These can bring about mistakes that become costly to your pain management practice. On the other hand, money is not always an issue. It can also lead to legal consequences like:

  • Imprisonment – for penalties and false claims submitted per file
  • Clinical Maltreatment – If there’s proof of deliberate distortion throughout quite a while and across countless patients. 

 Even though these may seem alarming, the most well-known result of billing issues is that insurance agencies will not reimburse your cases.

  1. Prior Authorization Delays

Prior Authorization (PA) setbacks can deprive physicians of time in catering to patients and increase their expenditures. Some medical insurance companies require prior authorizations (PA) before providing pain management procedures. It serves as a significant barrier for physicians to deliver quality care. PA helps with:

  • Monitoring healthcare costs
  • Proper approval from patients plan
  • Providing payers with a secure prescription for medicine and drugs

Despite this, the process can slow down the delivery of needed services and care for patients. To improve PA performance, physicians adopt the usage of Pain Management EMR Software. Electronic Prior Authorization integrates directly with your electronic medical records (EMRs). Healthcare professionals can use it to obtain prior authorization in real-time. Additionally, it eliminates the need for time-consuming paper forms, faxes, and telephone calls.

  1. No proper staff training

Unskilled staff in the healthcare industry might cause revenue cycle management issues. In relation, they might not bill or capture patient data correctly. Proper staff training is necessary to capture patient’s demographic information on the front end. Also, on how to translate that data to successful insurance claims after that. With that, patient schedules and registrations must also be accurate to avoid problems in revenue. Conducting staff training might be time-consuming, but it is worthwhile. It can increase cash flow well after, although it might also be costly. Moreover, your pain management practice will boost these areas:

  • Enhance job proficiency
  • Boost staff self-esteem
  • Employees will stay longer to your business

If you also think of outsourcing your revenue cycle management, talk to a Pain Management Billing specialist. Working with them can save you time and resources.

  1. Failure to follow up on Accounts Receivable (A/R)

A/R follow-up process can be a handful at most times. The team assigned for this is to consistently handle interactions with patients, healthcare providers, and insurance agencies. There are also processes that your team needs to complete:

  • Verification,
  • Charge entry
  • Payment posting

Medical billing specialists regulate the precise diagnosis and exact procedure codes based on the treatment plan. If your A/R team has issues regarding this, your practice might be at stake. Your practice cannot establish good revenue without a proper A/R process. Without it, it can lead to high collections of A/R, and backlogs will occur. The worse thing is that insurance companies will deny claims if your A/R team fails these processes. If you want to increase your profitability, you can read these 8 Tips in Pain Management Practice.

Tap Into Our Expertise

These are just some of the common problems associated with pain management practices. Think about outsourcing your revenue cycle management to trained and experienced medical billers and coders. Having people take charge of your medical practice problems and provide solutions is always a great idea to boost revenue.

At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.

Schedule a call with our experts today!

How to Achieve Clean Claims at First Submission July 1, 2021


What does a clean claim mean?

A clean claim is “free of any errors.” It is critical to submitting these the first time to ensure a smooth procedure. You can determine your clean claim percentage by the average rate of paid claims on the first submission. It’s best to keep this percentage high when running a lucrative surgery facility with limited resources and time constraints. So, how exactly can you secure a high percentage of clean claims while also establishing a consistent process? Here are seven steps that will help ensure clean claims submissions rate over 95%:

1) Be accurate and timely on patient information

Always ensure that patient information on claims is accurate and up to date. Patient demographic information, policy information, and medical information are all things to double-check. Detailed and up-date documentation allows your coders to give the most relevant procedure and diagnostic code(s) to support your claims. It will enable your practice to receive reimbursement for the service on time. Not only should the particular diagnosis and data about the surgery or treatment be included, but so should the patient’s medical history.

2) Verify patient eligibility as soon as possible

Providing patient eligibility verification at least two days before the DOS (Date of Service) will result in more accurate claim submission and fewer claim rejections. This eligibility verification approach also aids healthcare practices in maintaining a healthy cash flow by reducing write-offs and improving patient care. You must check all co-pays, deductibles, policy effective dates, in-network/out-of-network benefits, and other requirements during this step.

3)  Perform quality checks 

In the medical billing process, quality checks are critical in ensuring the submission of clean claims. Before submitting a claim, check it for demographic, coding, and submission issues. You need to double-check demographic inaccuracies, medical coding problems, and errors that arise throughout the submission process. Establish a system that gathers pre-authorization data on the front end and allows your billing staff to correctly measure denials for “no-authorization” so that the physician receives fast feedback. 

4) Submit prior authorization at least five days before DOS

To minimize prior authorization-related denials, submit it at least five days before the DOS. Use the best system to capture pre-authorization information on the front end accurately and allow your billing team to track “no-authorization” denials in real-time. It guarantees that the healthcare provider receives prompt input. The type of operation, which procedures require prior authorization, and whether the patient plan covers the treatment are all items that you must verify in this phase.

5) Know carrier-specific coding guidelines  

Claims may be rejected if their program doesn’t recognize a modifier. As a result, it’s essential to know what payers will and won’t cover. Using the correct modifier and adding the modifier to the correct method is among the details you should double-check.

Verify CPT and ICD compatibility, as well as the submission mechanism (paper or electronic). To ensure coding compatibility, create carrier-specific Local Coverage Determination (LCD) rules. Medical practices could also automate the claims cleaning process by developing rules engine software systems or outsourcing. You must know the answers to the following questions: 

  • What modifiers are accepted by the payers? 
  • Should you use a –50 modifier or a mixture of –RT and –LT for a bilateral procedure? 

6) Be up-to-date on new medical coding regulations

Some of the most significant difficulties affecting medical reimbursements are insurance claim denials and claim rejections. Medical coding guidelines and standards are also too complicated for healthcare providers to keep up with.

Outsourcing the claim submission process to the best medical billing firms can keep you up to date on all medical coding changes and ensure that your claims are accurately classified before submission. Claim denials are frequently the result of faulty coding or late claims filing. Claim scrubbing, in this case, swiftly detects and corrects coding problems before submission.

Healthcare practices can also leverage the automation process known as electronic claim submission to handle claims faster by installing the best medical billing software. This stage requires the verification of ICD and CPT compatibility and the kind of submission mechanism (paper-based or electronic claim filing) to ensure coding compliance.

7) Develop an effective denials management review process.

Most doctors are eager for documentation feedback, especially if their work is causing denials and hurting the practice’s bottom line. You can minimize clinical documentation difficulties by holding regular in-service events that keep physicians up to date on payer changes or new documentation needs.

Identifying all payer requirements in detail, from documentation and pre-authorization to allowable claims and proper formatting, and then applying that information to build a clean claims submission process can mean the difference between quick payments and late payments, or even non-payment some cases.

Tap Into Our Expertise

At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.

Schedule a call with our experts today!

Denial Management and Prevention Tips for Your Medical Practice November 23, 2020

Denied claims eat away 6-8% of a healthcare provider’s overall revenue. It hampers the financial stability and the growth of a practice. Contrary to popular belief, 90% of denied claims are actually preventable. You just need to take your denial management and prevention to the next level. We’ve gathered the best tips to stop these revenue leaks: 

1. Monitor you progress.

First, assess your denial management process frequently. You need to discern what’s working and what areas need improvement. To know your progress, you need to document all wins and losses for your unpaid claims. Thus, you’ll be able to use that data to improve the efficiency of your denial management strategies. 

2. Recognize why claims were rejected.

Understanding the causes of your denied claims will help streamline the process of maximizing your revenue collections and prevent the denial of future claims. Not all of your patients are knowledgeable about when their claims are being denied by insurance companies. Thus, it is your responsibility to educate them when tackling the issue. In connection, It is also important for the overall performance of your company to be able to assist them in a timely manner.

3. Identify the most common denials and trends.

Try to identify the types of denials that are most common to your organization. Initially, each form of denial can seem like a minor issue, but when you begin to track and examine these patterns, it can lead you to the root cause of some major problems in your organization.

4. Establish Incentive Programs

To motivate and encourage healthy competition, rewards and incentives should be put in place. Your staff should have the right motivation not only to successfully appeal denials but to recognize trends, share knowledge, and have great camaraderie.

5. Expedite your Denial Management Process

Denied claims may pile up over time and it may easy to lose track, which may lead to serious problems in the future. Utilize the latest technologies and tools that help you keep track, manage, and expedite your denial management processes. 

6. Do it within a week

You need to set high standards for timeliness in processing your denied claims. An effective tracking system would lead to more efficiency and help impact all factors of your practice. If you get a rejection from an insurance provider, there must be a procedure in order to ensure that the denial is handled in less than a week.

7. Leave it to the experts

You can never go wrong in outsourcing your medical billing and denial management processes to a trusted name in healthcare. It will surely give you the financial prosperity and stability that you always desired. Specialized teams that are highly trained in handling the complexities of the insurance system are used by the top denial management providers. You’ll have more time to focus on your core competencies by outsourcing your denial management needs.

Tap Into Our Expertise

At 5 Star Medical Billing, we offer the highest level of performance for high-quality medical billing. Let us help you during these dire times.

Schedule a consultation with our experts today!

Tips for Preventing Claims Denials November 5, 2013

Claims denials are a source of revenue loss for many healthcare facilities, specifically for those in Ohio. Yet organizations are often unaware as to how to improve the claims submission process. This lack of knowledge can result in repeated denials and interruptions in cash flow. Plus, when claims are not appealed or resubmitted for review, it basically means that doctors are working for free. In order to ensure that payment is obtained for services rendered – and that extra time and money isn’t being spent processing denied claims, it is important for billing staff to be efficient the first time around.

Here are a couple of ways an Ohio billing service can help physicians prevent denials:

Regularly monitor submission reports to track the reason behind each denial.

Monitoring reports is one of the best ways to find problems and figure out ways to fix them – and a medical billing company can help physician practices do this. Submission reports can be reviewed monthly – or more or less often, depending on the frequency of denials at a particular practice – and billers should take into account the number of claims that are getting denied, as well as what the cause is behind each one. Some common reasons for denials include:

  • Untimely filing
  • Incorrect modifier
  • Incorrect coding
  • Missing or incorrect information

Implement policies to prevent claims from getting denied in the future.

After identifying the reason claims are getting denied, it is necessary to address those problems so that they do not continue to occur. An Ohio billing service will know the reasons claims often get denied and will work with standardized submission and resolution processes to ensure that maximum reimbursement is achieved.

At 5 Star Billing Service, we handle high claims volumes and excel in accurately coding, billing, and finding data entry errors to prevent denials. We submit claims daily to prevent untimely filing; and we ensure that our physician clients in Ohio are satisfied with our medical billing services and benefit from high-performing billing departments. Our employees have in-depth knowledge of billing and claims submission processes, and they pay attention to small details to make sure that claims are submitted error-free the first time around. This means less follow-up work for us and more on-time payments for our clients.

To learn more about medical billing services for physicians in Ohio, call 480-821-1371 or contact us online.

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