Five Common Revenue Protection Issues
Advanced Data Systems Corp
Revenue Cycle Management, Practice Management & Medical Billing Software, EHR, and RIS.
No intro wording is needed.
1. Eligibility verifications must be processed ideally on scheduling appointments, and a few times again depending on how far ahead appointments are scheduled. Subsequent verifications are most easily done in batch directly from the scheduler.
2. Prior Authorizations were already discussed, but we can’t omit referrals. For example, if the person is a patient within a healthcare network and now needs a medical service that’s not provided from within that network, and you provide that service but are not in his or her network, you’ll need to ensure the patient has a referral authorization.
Hand-in-hand is the out-of-network (OON) problem. You’ll want to be alerted on scheduling, if possible, or at least at some point prior to appointments about OON appointments. But then, you’ll also want to see if any other providers can be selected instead.
3. Access to a Patient Responsibility Estimator while scheduling or any time in advance. When you can alert patients as to what they’ll owe based on the appointment reason, even if it’s a very close estimate, it will help in managing patient A/R. Even better is if you can do it again once actual procedures have been performed and before the patient leaves.
4. Denials. If you didn’t know better, you’d swear insurance companies are in business as much (or more?) to deny claims as they are to pay them. A best-case scenario to combat that is a mechanism for identifying claims likely to be denied, editing them first, and then submitting them. As a hand-in-hand backup, you’d want the ability to display any other denied claims, see their reasons for being denied, and then have a way to quickly edit and resubmit them.
It’s a combined ability to prevent denials proactively, with quick resubmission of others, all of which eliminates the denials pile-up.
5. Fully or partially missing insurance information. If this is a problem for you, having access to an accurate insurance discovery feature will help. You’d be surprised to learn how many patients actually do have coverage.
Medicare Advantage Plan Payment Cuts = No Impact on Enrollments
According to a JAMA report, while there have been Medicare Advantage plan (MAP) payment cuts under the Affordable Care Act (ACA), those cuts didn’t cause reductions in enrollments.
So, the good news is that MAP payment adjustments haven’t hurt access to care by patients, although those cuts could limit the program’s ability to offer supplemental benefits and in that way, harm beneficiary access to certain services.
The concept was to reduce federal spending by revising the methodology for calculating county benchmarks. In that effort, CMS enrollment, benchmarks, and payment data from 2008 to 2019 to was culled to determine the association between plan payment cuts under the ACA and MAP enrollment.
Click here for a related report from USC Schaeffer on how lower-spending people enrolling in MAPs in 2023 will lead to over $75 billion in overpayments.
Medical Decision Making (MDM) and E/M Coding
In a word: confusing.
Words: Now into mid-year, a brief E/M overview would be timely to make the remainder of 2023 as profitable as possible for you. Optimizing your E/M coding is a critical element in that effort but it can be confusing.
It’s confusing because E/M coding takes into account four levels of MDM. Click here to see the entire outline with each level’s variables. You’ll see the inclusions as of 1/1/23 in red. We’ve also listed them here:
Overall, selecting the correct E/M coding for every encounter can significantly impact revenue in one way or the other. You’ll want to be sure your E/M coding is spot-on without shortchanging yourself.
As you’ll see from the outline referenced above, or as you may already know, E/M coding is – confusing – with so many variables and possibilities. It’s made even more so with the new items for 2023.
NCCI Editing
In a word: deceptive.
As an added note to E/M, you’ll want to ensure proper NCCI adherence to avoid major denials which happen when individual claims for the same patient should be bundled into one master claim. If they’re not, the ones that should’ve been bundled will all undoubtedly be denied.
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We’re experienced with NCCI as well, and will issue alerts when needed helping to proactively avoid those denials and unnecessary (and incorrect) multiple claims.
Prior Authorizations
In a word: oppressive.
Prior authorizations (PAs) are time-consuming and burdensome when being done one-by-one manually by office staff since they typically involve culling (1) the patient’s demographics, (2) the ordering physician’s info, (3) medical necessity letters, (4) medical records with notes, (5) an explanation of why the requested/suggested procedure(s) need to be performed, and (6) other assorted annoyances.
Without first obtaining PAs or verifying if they were obtained when needed, you can count on those claims being denied. And almost universally, you can’t balance bill patients for these services.
You already know that getting PAs is incredibly time-consuming. A better approach is to have an automated option for it.
Inflators that Influence Medical Cost Trends and Pricing
“Medical cost trend” isn’t just an expression. It’s an actual calculation which is the percentage of expert anticipated treatment costs that will grow year-over-year as explained in the PwC Health Research Institute’s (HRI) medical cost trend report for 2024.
While there are a few ways to estimate medical cost trends, PwC uses per-capita costs of prescriptions and healthcare services. In 2024, PwC evaluated both the individual and group health insurance markets.
In that estimation for 2024, the medical cost trend is expected to increase by seven percent (7%) in the individual and group health insurance marketplaces. Meaning, insurers could expect to spend 7% more on healthcare costs.
Here are the reported inflators:
Click here for PwC’s full report and details on the bullets presented above.
Insurance Problems Faced by more than half of all Insured Adults
These problems diversely range from subscribers having payment discrepancies to those with limited mental healthcare coverage.
The Kaiser Family Foundation (KFF) online survey was conducted in February and March of 2023. It includes responses from 3,605 adults who had employer-sponsored health plans, Medicaid, Medicare, Affordable Care Act (ACA) marketplace plans, or military plans.
Perhaps unsurprisingly, approximately eight in ten respondents rated their health insurance plan as “good” or “excellent” which was most common among Medicare beneficiaries, including those enrolled in traditional Medicare and Medicare Advantage plans.
Insured adults who described their physical health as “fair” or “poor” were more likely to give their health plan a negative rating.
And even though most respondents gave their health plans positive ratings, nearly 60 percent reported facing a problem with their insurance in the past year.
Disclaimer: Articles and content about governmental information, such as CMS, Medicare, and Medicaid, are presented according to our best understanding. Please visit www.cms.gov if clarifications are needed. We are not responsible for typographical errors or changes that may have occurred after this newsletter was produced. Visit www.adsc.com to view our most up-to-date information. ADS RCM does not endorse any companies mentioned in our newsletters; you are encouraged to do your own research and due diligence on any that might be of interest.?