Medical Billing and Coding - 3Gen Consulting

As patient consumerization takes further hold, the impact of decisions in medical billing is getting more attention from the public and media. This is especially true in the area of errors in medical billing and coding.

Medical providers will benefit from understanding what frustrates patients and taking steps to reduce errors, as well as working with partners who can help them stay on top of changes in billing requirements and patient expectations.

Patients Are Frustrated With Medical Billing and Coding
A recent medical billing survey of 800 privately and publicly insured individuals who had at least one medical billing error over the previous five years yielded interesting results that reveal the frustration patients have with medical billing and coding outcomes.

The survey found that over two out of every five respondents indicated they were significantly frustrated when trying to address billing errors. Less than a third said they had extreme confidence in their ability to find an error in their bill.

Two of the most prominent challenges identified were people knowing who to contact and finding the right information during the bill collection processes. Financial leaders should know that this is an indication that the patient financial experience is more complicated than it should be and that they should look to make changes.

In cases where patients did find an error, it was most often by comparing charges with estimated costs (32%). 29% identified issues by comparing charges to the explanation of benefits, and another 29% found items on the bill that were different from the care they received. Overall, the primary motivator in correcting a billing error was saving money. Half of the respondents said they reported incorrect charges of at least $200, while those reporting issues of over $500 made up a quarter [1].

Issues With Medical Billing Resolution
Revenue cycle leaders should know that patients are also frustrated by spending time resolving bills. More than four out of 10 respondents reported spending up to a month getting bills corrected and seven out of 10 said they spent more than two hours on resolution.

Know that these challenges are an opportunity to improve the patient financial experience and rethink your approach to medical billing and coding to help maintain a patient experience that keeps you competitive.

Reducing Errors in Medical Billing and Medical Coding
The most direct way to address the patient experience in medical billing is to find ways to reduce your error rates. It will be critical to understand where the bulk of your errors are coming from so you can start with the root cause of your most common issues. You have a few options here [2].

Double Down on Data Accuracy
If you have a significant number of errors coming from patient data issues such as misspelled names or inaccurate policy numbers, cleaning up your data could go a long way in turning things around.

Take an End-to-End Approach
While errors can originate with your medical billing and medical coding staff, it’s important to look at the revenue cycle holistically so you can identify any issues along the line.

This includes front office staff who are responsible for insurance verification and checking eligibility during scheduling and check in. It also involves addressing clinician notes that need to be detailed to help ensure proper medical coding on the back end. Internal audits and review can be helpful in identifying where you have the most potential for improvement.

Know the Trends That Impact You The Most
While denials are a universal issue, everything from patient mix, to region, and even staffing can change your results. For example, with the end of the COVID-19 public health emergency, many hospitals and health systems might see an increase in denials because of issues and confusion around Medicaid enrollment. You also might have challenges around changing code sets or even losing extensive institutional knowledge to staff retirement. Whatever they are, identifying them is critical to finding an optimal starting point and forging a path forward.

Work With Your Staff
If you are looking to reduce medical billing and coding errors to improve the patient financial experience, it’s important to inform your staff why they might need to adjust their performance. This could include additional training on medical coding and getting ahead of new code sets, but also simply explaining that they are an integral part of the patient experience – information that might be new to them as back office workers.

Consider Working With a Partner
While getting medical coding and billing error rates up to a level that supports a healthy patient financial experience might be new to your organization, an outsourcing partner can provide experience in quickly reducing error rates. They can employ tested methods and save you the trouble of implementing tactics that might be outside your expertise.

Centering patients in your medical coding and medical billing strategy might be new to you, but know you have access to support. To learn how we can support your patient financial experience efforts, start here.

References
[1] J. Asser, “Patients frustrated with process to address billing errors,” HealthLeaders, 19 January 2023. Available: https://www.healthleadersmedia.com/revenue-cycle/patients-frustrated-process-address-billing-errors.
[2] J. Finnegan, “4 ways to reduce medical billing errors and claims denials,” Fierce Healthcare, 3 August 2017. Available: https://www.fiercehealthcare.com/practices/4-ways-to-reduce-billing-errors-and-claims-denials.

The No Surprises Act is in the news yet again to start off 2023, promising more disruption for medical billing and coding services.

On February 6 of this year, District Judge Jeremy Kernodle issued another judgment in favor of the Texas Medical Association (TMA) – one that providers across the country will look at positively. He ruled that a revised arbitration process favors insurers and that challenges to parts of the final rule are unlawful. The president of the TMA, Gary Floyd, MD, weighed in with his opinion. “The decision will promote patients’ access to quality care when they need it most and help guard against health insurer business practices that give patients fewer choices of affordable in-network physicians and threaten the sustainability of physician practices.” [1]

The suit, which was originally filed in September, was done in conjunction with UT Health Tyler Regional Hospital and a physician and gained the support of 30 other national and state medical groups in the form of amicus briefs. Insurers have presented the idea that providers were baseless in claiming there were “early signs of a beneficial trend, where the [No Surprises Act] has furthered good faith network negotiations over reasonable rates.” The insurance trade group AHIP, stepped out in support of HHS [1].

Previously, the TMA filed a lawsuit in October of 2021 which challenged the rule with the claim that it didn’t follow direction from Congress in implementing the dispute resolution process. It was called “short-sighted” and accused the rule of driving down reimbursement rates while encouraging insurance companies to narrow networks. It was ruled against by a federal judge in February 2022.

What Is the No Surprises Act
As this piece of legislation continues to pop up in the news, providers considering the future of their medical billing and coding services will benefit from understanding it from the beginning.

The term “surprise medical bills” refers to the situation in which insured consumers receive care from an out-of-network provider like a hospital, doctor, or provider they didn’t choose, inadvertently triggering billing they didn’t authorize. This has been found to happen in around one out of five emergency room visits. On the non-emergent care side, about 9%-16% of in-network hospitalizations have been found to potentially include unexpected bills from an out-of-network provider like an anesthesiologist the patient had no hand in selecting. These bills are an issue for patients because they often result in significant financial burden through denials or out-of-network cost sharing. Consumers are also subject to “balance billing” from providers that are out-of-network that don’t have contracts to accept discounted payment rates from a health plan. The bill potentially applies to around 10 million surprise, out-of-network medical bills each year.

This most recent news addresses the arbitration process which allows for the determination of surprise bills through negotiation between providers and insurance plans and, if negotiations are not effective, the use of an independent dispute resolution (IDR) process.

But the dispute resolution process has remained a challenge, with providers issuing more submissions for appeal than was expected. Providers have made such heavy use of the IDR process that the system has become clogged and in response, the Biden administration has raised fees for engaging in the process. In December of 2022, the Treasury Department and the Department of Health and Human Services (HHS) made a significant increase in the resolution fee, increasing it to $350 from $50 per party for each disputed claim. The goal was for the fee to be a deterrent to use. These charges went into effect January 1, 2023 [2].

Patient Impact of the No Surprises Rule
Providers who care about their medical billing and coding services and work with medical coding outsourcing companies are keeping a close eye on how the bill could impact patients. This is because patient perception impacts how they choose providers and, as more patients are aware of what the practice of surprise billing can mean for them, they will predictably weigh that in their decision-making. For example, before regulation became more intense, private equity firms were taking advantage of the opportunity to bill out-of-network services from tens of thousands of physicians which they used to staff hospitals. This included the emergency department, which left patients caught in the middle.

Impact on Provider Medical Billing and Coding Services
So, what does all this mean for providers? It means a rocky future for surprise billing and arbitration, complicating billing strategies for providers across the country. Many leaders will not only have to consider the impact of their contract negotiations, but also how their approach to medical billing will intersect with future changes in the legislation. Some providers who have already considered medical coding outsourcing companies are also looking to outsource medical billing to relieve themselves of challenging decisions as the legislative environment continues to evolve. If you are in this position and want to talk more about how the No Surprises Act could impact your organization, contact us today.

References
[1] J. Emerson, “Federal judge rules against HHS — again — over surprise-billing arbitration rule,” Becker’s Healthcare, 7 February 2023 . Available: https://www.beckerspayer.com/policy-updates/federal-judge-rules-against-hhs-again-over-surprise-billing-arbitration-rule.html.
[2] L. Santhanam, “How this law reshaped medical billing, and what challenges remain for patients,” NewsHour Productions LLC, 20 January 2023. Available: https://www.pbs.org/newshour/health/how-this-law-reshaped-medical-billing-and-what-challenges-remain-for-patients.

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