Measure the Cost of Billing and Improve Your Bottom Line
Dr. H. James Harrington has been involved in quality and performance improvement projects since the 1950s. He is credited with the following statement, “Measurement is the first step that leads to control and eventually to improvement. If you can’t measure something, you can’t understand it. If you can’t understand it, you can’t control it. If you can’t control it, you can’t improve it.” 1
Healthcare has explicit and complex reimbursement guidelines for most in-office and in-facility procedures, yet the most perplexing problem is how to measure the cost of billing the procedure, reworking a denial or writing-off any uncollectable charges.
Challenge
How do you – a provider, a billing company or a clearing house – apply edits to claims so that you or your client base are paid correctly on the first claim submission without incurring additional expenses of claim re-submissions?
Solution
In an article by Carl Mays II titled “Medical Billing Services Must Use Scrubbers” over 90% of the claims submitted after using a claim scrubber got paid on the first submission. A claim scrubber will reduce your outstanding accounts by 40-50 days. 1
Claim scrubbers or editing engines, can be programmed to be as simple as checking for required fields on an electronic claim by alerting the claim submitter to missing or empty fields – these types of edits are commonly referred to as technical edits. Complex editing or compliance edits utilize a more robust coding and billing engine can edit for medical necessity, unbundling, bundling, utilization and code and modifier validity checking.
A claim editing engine can be customized with rules which target reimbursement requirements that are specific to a region, a payer or even your practice. Rules can be built to prevent common or complex denials. Editing engines prevent incorrect claims from being submitted to a payer which will be denied incurring additional expenses to re-work and re-submit a claim. Edit engines allow for corrections to the claim before it is submitted to a payer and can be used at any provider workflow level.
For instance, the diagram below is an example of a typical workflow for a patient encounter, at each stage an edit engine can assist the staff to check for medical necessity, apply regulatory and compliance edits and then perform a final analysis of the claim before the claim is sent to the payer automatically and in real time. The engine can provide reports for analysis by edit, provider, or offending code for measurement and education of staff. Not only can this solution be implemented at the practice level, it can also be integrated with a clearinghouse, practice management or EHR system.
Patient Encounter and Claims Editing
At the Pre-Encounter stage – LCD/NCD checking occurs upfront where the ABN can be signed. During the Encounter stage – coding, regulatory and utilization edits are deployed. At the back-end stage, before the claim is submitted to the payer, a final edit of the entire claim is done utilizing claim history, to review and allow for corrections. Claim reporting features allow for detailed provider claim analytics.
Context 4 Healthcare offers an array of edits that reflect your patient encounter workflow at each stage and offers not only real time editing and correction but can be integrated into your practice management system. Analytics and dashboards are also a featured that allows you to view and measure your success rate. Some of the edits include:
§ Unbundling
§ Re-bundling
§ Service over-utilization
§ Inappropriate and unnecessary services
§ Modifier appropriateness
§ Procedure/diagnosis attributes
§ Procedure to diagnosis relationships
§ Code validity
§ Data integrity
§ Customized Edits
§ ICD/CPT/HCPCS combinations
§ LCD/NCD
§ CCI
§ Medicare/Medicaid
§ Payer specific
§ Recovery Audit Contractor (RAC) issues
Let us help you measure and improve your bottom line today.
1. http://www.littlethingsmatter.com/blog/2010/08/23/you-cant-improve-what-you-dont-measure
2. Carl Mays II-http://www.claimcare.net/medical-billing-blog/bid/5473/Medical-Billing-Services-Must-Utilize-Scrubbers
3. Partners in Profitability How to choose the right clearinghouse for your practice- Navicure Whitepaper
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