Physician Medical Billing Is Critical to Practice Health

Why A New Look at Physician Medical Billing Is Critical to Practice Health

Challenges in physician medical billing have changed. 

From the impact of a pandemic, to shifts in government, to changes in patient demographics, practices have seen the factors that shape their physician billing services turn upside down in recent years. This means that many practices are in a position of playing “catch up” in their physician billing services. But while the path forward might be unclear, there are ways that practice revenue cycle leaders can make changes to remain healthy and align their physician billing strategy with modern challenges. Here is a look at the issues you face as well as how to get past them. 

Modern Challenges Complicating Physician Billing Services
Post public health emergency, many practices are faced with an opportunity to assess the environment they’re functioning in for better understanding of how to move forward. Here are some key challenges to look out for at your practice [1]. 

Manual Processes Are Slowing You Down
Are you still relying on paper as the backbone of your physician billing services? Many practices are sending paper bills to their patients, despite the fact that under 10% of patients want to pay a bill using a paper check. 

Beyond this, paper statements are often confusing for patients and don’t clearly communicate how much they’re owed. Manual processes slow down patient payments, with 70% saying it can take more than 30 days after a patient visit to collect. But paper isn’t only a problem with patients. Managing appeals via manual processes can slow down your cash flows from insurance companies as well. 

You Aren’t Thinking Digital
Before the COVID-19 pandemic, technology for collection was a “nice to have”, but today, it’s a necessity. Surveys have found that as many as three out of four providers still use paper despite consumers wanting online payment at about the same rate. Unfortunately, 40% of providers believe that billing and collection practices have no impact on the patient experience. 

If you aren’t open to using digital in both patient and payer collection in physician medical billing, you’re falling behind the curve and are missing out on revenue from patients and insurance companies. 

You Don’t Understand Patient Payment Trends
High deductible health plans might have dropped in use between 2020 and 2021, but the deductibles themselves have increased. The same issues apply to traditional insurance where copays and deductibles are growing. Medical practices should be paying attention to hospital trends, where balances are getting higher, and patients are demonstrating increasing difficulty in meeting their financial obligations. 

This is a challenge to physician medical billing, especially if you aren’t tracking trends and haven’t adjusted for changes to your approach to collections since before the pandemic. 

How to Adjust Your Physician Billing Services
Now is an excellent time to look at your approach to physician medical billing and make changes that will sustain you even through future upheaval. Here are some places to start. 

Ensuring Funds Are Available For Growth
As you move forward, you will have multiple decisions to make in terms of where to invest for growth and sustainability – and many of these will require financial investment. This means that your first step will be making room in your budget for potential future opportunities. 

For example, this could include things like new practice management software, training for staff on how best to collect from commercial insurance, and bonuses to retain personnel who are the most effective and who will best support your practice as new challenges arise. Keep in mind that this is a long-term need. Modern challenges in physician medical billing will continue to evolve and to stay healthy, your practice will need to keep up on an ongoing basis. 

Investing in People
There is an ever-increasing amount of technology available to help you get past manual processes and keep up with patient payment trends. But this doesn’t mean you can skip investing in people. 

Your staff will need ongoing training on things like medical billing and coding, new technologies, process improvement, and maintaining a positive patient experience as you work to keep your practice healthy. This level of focus has to happen at the strategy level, with commitment from your practice to prioritize people from now on. 

This is more than just an internal question. Many practices see benefits from expanding their access to trained staff who understand the specialized needs of their practice by partnering with external experts. Know that, as challenges become more complex, the less an individual practice will be able to handle physician billing services alone and the more they will need to consider solutions like outsourcing to access knowledge and flexible talent. 

Attracting top leadership who are up to the task
Physician owners are often in a difficult position and sometimes, they aren’t really running their practices with a business mindset. This isn’t always a choice. They could very well be open to ideas to improve practice health, but don’t have the people underneath them that they need. 

This is where strong leaders on the administrative side come in. As practice management becomes increasingly complex, practices will need leaders who are up to the task of today’s challenges, and not just those who have demonstrated past successes. 

In today’s fast-changing environment, every practice needs access to a partner who understands physician billing services and can help them adapt multiple aspects of their business to meet the issues of the future. To learn how we can be that partnership for you, contact us today.

[1] B. Crotty, “4 Key payment trends impacting physician practices,” MJH Life Sciences, 23 November 2022. Available:

Revenue Cycle management Services

Medicaid Disenrollment Means Providers Should Rethink Revenue Cycle Management Services

Medicaid unwinding has been a critical topic around revenue cycle management services for months now, and this is because providers will be directly impacted. Most providers should expect to see serious upheaval in their revenue cycle management services as patients are kicked off Medicaid rolls.

Medicaid Unwinding Explained
During the height of the COVID-19 pandemic, enrollment in Medicaid increased, largely thanks to the continuous enrollment provision that prevented people from having their coverage removed. For providers, this meant an unprecedented stability in the Medicaid enrollment in their care communities. But since the end of the public health emergency (PHE) this has changed. The Kaiser Family Foundation (KFF) estimates that anywhere between 8 million to 24 million people will lose their coverage as the continuous enrollment provision unwinds [1]. 

Providers such as hospitals, health systems, home health agencies, and physician practices will need to pay attention, possibly even considering working with a revenue cycle management company. But first, it will be important to understand the possible outcomes during the unwinding. 

How States Will Be Impacted
Not every state will see the same issues, so providers should be working to understand their individual risk. 

For example, Utah is expected to have the highest proportion of members who are taken off the rolls, with a possible percentage difference of 32.5%. After that is Indiana at 28.1%, Minnesota at 27.2%, and North Dakota at 26.5% [2]. States with the lowest impact include:

  • Nebraska
  • Connecticut
  • Kansas
  • Alabama
  • Alaska
  • New Mexico 

Providers in each of these states are already working on plans to adjust. Indiana University Health, for example, is offering personal assistance to members to help them keep their benefits or find a path to new coverage. They’re doing this through financial counselors at their hospitals and cancer centers as well as through community outreach events. 

Florida’s Memorial Healthcare System is in a state that could see around 1 million people disenrolled during the unwinding. The health system is working on auto-enrolling based on information gathered by the state but is also aware that work and preparation will need to happen for people who aren’t able to auto-enroll and who might need support looking for alternative coverage. 

The Uninsured Challenge
During the three-year period of continuous enrollment (February 2020 to March 2023) Medicaid enrollment increased by around 20 million people. This was the reason the uninsured rate fell to its lowest level at the beginning of 2022. Unfortunately, according to the recent KFF survey, only about one-third of states had the ability to project coverage losses around disenrollment, meaning providers will face multiple challenges in establishing revenue cycle management services that align with their needs as uninsured populations rebound [3]. 

Providers should expect that, while renewals resume for Medicaid enrollees, they will see substantial uncertainty around how many people will lose Medicaid coverage, how many will find their way to other coverage, and how many will become uninsured. That said, most providers can be sure that they will see an increase in their uninsured rates, on top of increases in enrollment in CHIP and private health insurance. 

But exact predictions will be difficult. Consider that, since Medicaid enrollment was automatically sustained through the height of the pandemic, some people who are currently listed as enrollees through administrative data could have started working and might now have insurance coverage under an employer. At the same time, the federal surveys that measure uninsured rates (through self-reporting) show smaller increases in enrollment than administrative data. 

Hospitals Could See Mixed Results
Hospitals will need to pay close attention to their revenue cycle outcomes. Hospitals now are dealing with changes from the end of the PHE including shifts in bad debt and charity care as well as other factors tied to the end of the continuous coverage requirement. 

Kaufman Hall reports that the April increases in bad debt and charity care could be directly tied to Medicaid disenrollment. They also report that hospital volumes have dropped, including both inpatient and outpatient. These decreases combined with increases in charity care and bad debt could be a signal that widespread disenrollment is at hand. Erik Swanson, senior vice president of data and analytics believes there is a link. “With states conducting their Medicaid eligibility redetermination, it’s predicted that hundreds of thousands of people will ultimately become uninsured. The data indicate that we may already be seeing the effects of disenrollment materialize with patients less likely to seek out the care they need and a continued rise in bad debt and charity care.” [4]

Hospitals will be navigating these changes while paying more for supplies and labor, stressing the importance of looking for a revenue cycle management company who can help them ride out these trends in the best way possible. 

Nursing Homes Are Waiting to See Outcomes
Even as hundreds of thousands have already been removed from Medicaid rolls, the impact hasn’t been severe for Medicaid-dependent nursing home residents according to McKnight’s Long-Term Care News. Their survey of a dozen sector associations about the end of the COVID-19 PHE and Medicaid unwinding found reports of no significant impact. As a result, members are following their standard processes to continue serving their Medicaid-eligible residents. That said, in Oklahoma, where 70% of disenrollments have been a result of procedural issues (vs. proven ineligibility), neither the Oklahoma Health Care Association or LeadingAge Oklahoma could comment on the situation in nursing homes [5].

How to Approach Revenue Cycle Management Services
This is a time of ongoing uncertainty for providers. Cash flows will undoubtedly be impacted even as expenses are increasing. Providers should be taking a step back to examine their approach to revenue cycle management services, assessing whether they have the ability to monitor and respond to this type of unprecedented change. Most will also need to consider partnering with a revenue cycle management company to navigate the coming changes. To learn more about a revenue cycle management company that can help you in this process, start here.

[1] J. Tolbert and M. Ammula, “10 Things to Know About the Unwinding of the Medicaid Continuous Enrollment Provision,” KFF, 9 June 2023. Available:
[2] R. Wilson, “How many people could lose Medicaid coverage, state-by-state,” Becker’s Healthcare, 31 March 2023. Available:
[3] A. Burns, E. Williams, B. Corallo and R. Rudowitz, “How Many People Might Lose Medicaid When States Unwind Continuous Enrollment?,” KFF, 26 April 2023. Available:
[4] J. LaPointe, “Hospital Finances Break Even as PHE Ends, Medicaid Unwinds,” RevCycleIntelligence, 31 May 2023. Available:
[5] J. R. Towhey, “As Medicaid disenrollments surge, concerns about nursing home residents persist,” McKnight’s Long-Term Care News, 5 June 2023. Available:

From the Desk of CEO

Physician Billing Should Be Ready for the Protections of Medical Conscience Bill

If you’ve been paying attention to what’s going on with healthcare in Florida, you probably know that the Florida House passed a bill that gives physicians the option to opt out of services for reasons of conscience – meaning they won’t face negative repercussions for refusing to perform a medical procedure. But payers are mentioned in the bill too, and this isn’t getting enough attention.

If you read the text of the bill, payers are mentioned right alongside providers. For example, look at this wording [1]:

 “A health care provider or healthcare payor has the right to opt out of participation in or payment for any health care service on the basis of a conscience-based objection.”

So, payers are allowed to withhold payment for services based on “Conscience-based objection”. According to the bill, this is defined as,

“…an objection based on a sincerely held religious, moral, or ethical belief. Conscience, with respect to entities, is determined by reference to the entities’ governing documents; any published ethical, moral, or religious guidelines or directives; mission statements; constitutions; articles of incorporation; bylaws; policies; or regulations.”

This definition offers a lot of leeway.

So, what does this mean? I don’t think it’s cause for alarm, but I do think providers who could be affected should keep a close eye from a physician billing services perspective, specifically around denials and during contract negotiations. This is because the bill opens a potential new path for denials and payers not properly compensating providers – and providers would be left with few options if they’re in a state that takes similar measures.

I want to be clear that I don’t see this as a blank check for payers to deny claims however they like. But I do think that it could mean providers in multiple states around the country might need to shift their thinking around denials management and physician billing services.

Now is as good a time as ever to refresh your denials management strategy and approach to physician billing services with coming changes in mind. And if your state doesn’t have comparable legislation in play, you’ll want to watch the political news in your area to see if something similar, even if less aggressive, might be headed your way.

[1] Florida House of Representatives, “CS/CS/HB 1403: Protections of Medical Conscience,” 2023. Available:

Hemant Apte, Chief Executive Officer in

Hemant Apte, Founder & Chief Executive Officer of 3Gen Consulting, is a seasoned executive leader with deep domain expertise in US healthcare management practices. He founded 3Gen Consulting in 2006 and has been instrumental in offering thought leadership to his clients and providing services and solutions that are unique in the market.
Biggest Risks in Physician Billing in 2023

Biggest Risks in Physician Billing in 2023

Physician billing companies know a secret – keeping on top of risks in physician billing services is one of the most effective ways to keep cash flows healthy and practices functioning at their best.

That’s why we’re going to walk you through the biggest risks to physician billing right now in 2023.

Volume and Resource Fluctuations Continue
While the worst of the pandemic-related volatility is likely behind us, physician billing will still need to adjust for unpredictability. This is because physician practices are dealing with COVID-19 challenges in addition to the waste and abuse issues that were entrenched well before the pandemic. So now physician offices are dealing with yesterday’s problems on top of longer visits, more visits for therapies and early refills, COVID-19 diagnoses, and disbursement of excess pharmacy and durable medical equipment. These things make billing volatile and complex and are why many practices are considering working with physician billing services.

And while volumes have returned to normal for many, this is only part of the story. Some payers are reporting increases in deferred care, but not quite at the rates expected, while others are seeing more than projected. Labor challenges also continue to rage on, with many practices still figuring out their approach to remote work and retention and considering physician billing companies. This is happening with both providers and payers.

These issues have contributed to an increase in payment errors and billing inaccuracies in many areas. To minimize risk, providers should be ready to address these issues both on their end and on the payer side [1].

Don’t Overestimate AI in Physician Billing Services
Medical billing has been heralded as one of the best use cases for artificial intelligence (AI) in healthcare, and for good reason. Medical billing and coding rules are constantly being changed by payers, documentation requirements are always shifting, and coders are constantly inundated with new code sets. All these issues slow down reimbursement, contributing to denials and clogging up the appeals process. AI has been hit or miss in clinical areas, but since medical billing and coding are text-centric, they could hypothetically be a perfect fit, allowing smaller teams to work on claims that are more complex than their norm.

But much of the optimism hasn’t turned into reality. Organizations who’ve stepped out early into AI have had significant growing pains, especially in terms of data quality. AI models live by the principle of “garbage in, garbage out”, so that even practices that are excited about the promise of AI are learning that they have to do significant work to assess their coding practices and making sure they’re getting highly correct information from the beginning. They also need enough data points or sets to make sure prediction models are accurate since using amounts that are too small can dilute the power an analytics technology needs for success [2].

So, while the promise of AI is on the horizon, most physician practices will need to take an honest assessment of their goals, resources, and current state of tech readiness to avoid the risk of adopting solutions before they’re ready.

Upcoding in the Age of COVID Can Cause Problems
One of the more grounded and classic risks that physician offices will face in 2023 is the problem of upcoding – a problem that, if too extensive, can trigger allegations under the False Claims Act, leading to potential audits and financial penalties.

Upcoding is simply submitting a claim with higher or more extensive medical coding than the documentation or circumstances support, usually to get higher reimbursement rates than lower codes provide. A classic example is evaluation and management (E/M) codes being billed at a higher level (such as five when documentation only supports a level two). For example, telehealth fraud was found to have increased through improper billing and upcoding during the COVID-19 pandemic. State and federal regulators had relaxed restrictions to allow increased access to telemedicine, resulting in an 11,000 percent increase in virtual appointments during the pandemic and Medicare primary care visits jumping by more than 43% in the first three months of the pandemic. But in early 2021, the Department of Justice made an announcement that it had brought in over $2.2 billion in judgments and settlements from fraud and False Claims Act cases with more than 80% of False Claims Act recoveries in FY 2020 coming from the agency resolving fraud and enforcement actions [3].

But upcoding doesn’t require direct malicious intent. A practice can be at risk of upcoding practices simply because of poor training or bringing on an employee who previously worked at a less scrupulous organization. This is why many practices work with physician billing services to level out the risk.

The Risk of Audits Continues
While connected to upcoding, it’s worth looking at audit risk on its own, even if you work with physician billing companies.

Consider that the Office of Inspector General (OIG) plans on reviewing E/M services provided by physicians in the emergency department. The agency is keeping a close eye on how physician practices are being billed in 2023. While this example is in emergent settings, physician practices should take it as a warning. It can be helpful to have someone review your claims, or you might even consider working with a physician billing company to minimize risk.

Use these points as a checklist to bump against your own processes and best practices. As you move forward, you’ll find areas for improvement, but also areas where it might be smart to start looking at physician billing companies that you can partner with to improve financial outcomes. When you’re ready to take that step, start here.

[1] S. Mantha, “Addressing 3 pandemic-induced payment integrity challenges,” Industry Dive, 30 January 2023. Available:
[2] J. LaPointe, “Medical Coding is the Next Stop for Artificial Intelligence in Healthcare,” TechTarget, Inc., 3 October 2022. Available:
[3] P. Giancola and C. Stedman, “Telehealth Fraud Triggered by COVID-19 Pandemic,” JD Supra, LLC, 16 February 2021. Available:

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