It has been estimated that more than $ 200 billion is spent each year in the United States on medical claims submission and reimbursement procedures, but the sad truth is despite the colossal amount of money allocated, there is a failure rate of 22% and above when it comes to denial and underpayments. This has really been pushing the healthcare costs skywards and practices are finding it ever so difficult just to stay profitable. What really is the problem here? Let’s look at this in detail with an example.
A small clinic on the outskirts of Charleston, South Carolina has a sizeable number of Medicare patients. Of late there had been an increased number of individuals in the neighbourhood who had received notices from Medicare; thus the clinic experienced an increased spate of those scheduling for an Annual Wellness Exam or Welcome to the Medicare Exam or an annual routine physical, as the case might be. The front desk and the physicians did their best in explaining to the patients what copayments and deductibles they might expect from each of these exams. The Medical Billing Department, which had recently converted to electronic billing and had recruited a much younger staff, did its best in billing the respective insurances including Medicare.
But it seemed like something was not right, when more often than not Medicare refused to pay for many of these exams and patients were made to bear half of the burden most of the times (amounting to more than $100) and sometimes the whole amount (in excess of $200), in case they lacked secondary insurances (like TriCare4Life). The old timers who had handled this in the past via paper claims could not be reached and the medical billing team was under increasing pressure to find out what was amiss. It was then an outsourced medical billing vendor was consulted. They immediately went through the EHR software’s automatic code suggestion engine and found that the software erroneously suggested only CPT code 99397, when it was prompted for exam options. It goes without saying that the right code to bill for newly eligible Medicare patients is the HCPCS code G0402, which was not even an option in the EHR software. And the young medical billing team were too naive to see this.
The clinic later on was forced to bring back one of the older staff from retirement and contracted the services of the medical billing vendor on a long-term basis for coding assistance and some of the other revenue cycle management tasks. The clinic also, on the advice of the vendor, switched from the above EHR to a PracticeFusion-Kareo combination, which made sure that incidents such as the one mentioned above never recurred.
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