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New Generation Revenue Cycle Management: Prevent Claim Denials

WRS Health recently produced a white paper titled, “New Generation Revenue Cycle Management: Not Your Grandmother’s Billing System,” which examines new, cloud-based revenue cycle management tools for medical practices. Today, in part four of our six part blog series, we examine how new generation RCM tools can help prevent claim denials and increase a practice’s ROI.

Part 4

In regards to claim submission and its effect on practice revenue, the AMA points to a 2007 National Healthcare Exchange Services (NHXS) study, which found that the average physician billed for 374 services per month, and the average monthly underpayment rate was a total of $889 per physician. “Using the typical research and correspondence methods employed by most physician practices, the cost to dispute a single underpaid service is $22 for the physician practice and equally as much or more for the health insurer. The economics of dispute resolution overwhelmingly favor first-time payment accuracy by the health insurer,” stated the AMA.

Claim Rules Engine 

How can physicians get paid correctly the first time that a claim is submitted? A powerful system, which combines automated eligibility checking with a powerful rules engine comprised of 50,000 of claims rules, ensures that physicians get paid correctly the first time a claim is submitted. A rules engine that is always updating and adapting its rules alerts practices of the most current claim denial trends, enabling the practice to constantly improve its collection rates. A system with an advanced rules engine prevents your claims from being denied, which means you save more money and spend less time resubmitting claims. If you have real time information at your disposal you can act on it. 

Local Coverage Decisions

Look for an advanced system where local coverage decision ICD-CPT crosswalk edits and Correct Coding Initiative CPT bundling edits happen automatically. A top system that can provide direct access to CMS’s database on a quarterly basis, instantly provide you and your staff with the most up-to-date rules. When this data is combined with real-time form edits, it ensures that items, such as insurance card number and demographic data, are entered correctly. When a claim is rejected, you immediately see the clearinghouse or insurer denial reason so that rejected claims can be instantly corrected and resubmitted. When billing for multiple procedures, a system that gives you modifier alerts allows claims to be correctly processed. Likewise, incorrect claims are identified and the user is given an alert. 

Optimized Process for Working Rejections

A medical billing solution that provides you with a suite of reports that are run automatically and present you with the information you and your billing staff need also ensures timely, correct and complete payments from all insurers and patients. Reporting is one of the major features and benefits that can make a significant difference in your billing solutions. It can help you target A/R days, provide productivity reports, enable you to view collections by payer and referring provider as well as post lag.

Anita Jackson, M.D. of Greater Carolina Ear, Nose & Throat in North Carolina said, “Our cloud-based billing system allows us to be able to look at every claim and the status of its filing. We can see whether it’s been filed, whether it’s gone to secondary (insurance), whether it was filed but never received or whether it’s pending, and that’s really important.”

Jackson added, “My staff inputs all the data. Unlike paper charts where things can get lost and go missing, the Cloud EMR is a long-term record. Whenever a claim is denied, you can go back and determine whether you had the right (insurance) number or not. It’s helpful to have a copy of the card, but at least you have something to compare to say the data entry was inaccurate.” 

Syed M. Rizvi, M.D., owner of S.M. Hammad Rizvi M.D. Inc. in Upland, California, is able to track any rejected claims with his new cloud-based system. “I‘ve seen a much better improvement in revenues, I’ve seen much better cash flow. Through the billing system, we can track which claims were rejected. We get the electronic rejections and we can fix the problem quickly. We don’t have very many rejections. The last time, we had 99.9% accuracy,” said Dr. Rizvi.