Medical professionals face increasing financial challenges when operating their practice. Insurance denials, endless appeals, changing coding guidelines, and shifting payor policies can easily financially disrupt a medical practice. Steady cash flow is paramount to growth. As such, improved insurance reimbursement rates are critical to a practice’s success.

Reimbursement Issues

Patients and providers both depend on insurance reimbursement for most healthcare. Physician practices often struggle to get paid. Fluctuating reimbursement schedules, audits, patient frustration, coding errors, and incorrect information, set the stage for claims rejection. This constant payment battle can delay needed patient treatment and can leave medical professionals unpaid when providing necessary services.

Payment for services is standard practice in business. A price and term agreement is reached, customers receive their purchase, and sellers are compensated. Healthcare payment systems work differently. Treatment is often provided prior to payment. The payment for care process often includes a quagmire of reimbursement issues rife with challenging pitfalls.

Due to confusing reimbursement deadlines and schedules, it is difficult for physicians to know when, or if, they will be paid. Insurance companies can easily deny claims or request supplemental information, requiring practices to submit detailed appeal forms and fight for payment. Surveyed healthcare administrators list appeal claims as their most frustrating challenge.

Many insurance companies regularly audit claims to scrutinize and to “prove accuracy”. Compensation for previously rendered medical services is often delayed or reduced as a result. The medical provider may go completely unpaid when an audit decides a service provided wasn’t covered by the plan.

HCPCS Code Considerations

The non-payment of Medicaid and Medicare related services are known issues. Their requests and denials can make running a practice a challenge.  Providers often fight multiple rounds of denials and appeals prior to reimbursement. If the insurer ultimately decides not to pay, a provider must ask a patient for the unpaid service or absorb the financial loss.

Medicare HCPCS codes, and the excessive documentation required for reimbursement is a major onus. Medicare and Medicaid requirements can make claims very difficult. The MPFS is a list of more than 7000 billing (HCPCS) codes. The MPFS uses three relative value units (RVUs) to calculate payments. These include the work RVU (time associated with providing a Medicare-related service). The practice expense RVU (the practice maintenance costs), and the malpractice RVU (cost of malpractice insurance). The MPFS allows for variations in geographics and generally pays 80% of the service charge, with the patient responsible for the remaining 20%. A simple one-digit error in a claim can easily disrupt this complex payment process.

Nonparticipating healthcare providers are those enrolled in Medicare but who don’t sign form CMS-460. These physicians accept reimbursement assignments on an individual case and are paid a 5% reduction as a result. The Medicare payment is issued to the patient, who is responsible for paying the provider, creating additional financial risk. The No Surprises Act worsens the issue. Unless a patient consents to out-of-network payments for emergency services and certain scheduled services, the law protects the patient from surprise medical bills. Correct claims submission protects the physician.

Lack of Accurate Documentation

Denied claims numbers continue to rise for many reasons. Lack of accurate information is a major trigger. Incomplete, inaccurate, unorganized records, or a lack of diagnostic and service details allow payors to push back payments. Poor documentation also reduces compliance, decreases patient safety, and the continuity of care when changing providers. When recording patient encounters, capture everything.

Reimbursement Strategies

It takes technology to succeed in today’s medical billing environment. Many medical coding and administrative teams lack training for increasingly complex platforms, and a rise in denials is often the result. Staff education can dramatically boost reimbursement success. Claims will continue to bounce when billing processes are inadequate.

When every step is followed perfectly, some valid claims can, and will always be denied. 75% of healthcare providers report a 15% denial rate resulting in a huge loss of revenue. Reasons cited by payors include coding errors, medical necessity issues, and incomplete information. Your healthcare practice’s financial stability is threatened by unresolved denials, submitting clean claims should be a priority.

Complex Coding and Billing

Healthcare billing codes use confusing terms and guidelines that grow more convoluted with time. While accurate codes are key for proper reimbursement, staying updated and avoiding mistakes is difficult. Proactive strategies centered around documentation, including using improved technology and effective analytics, can smooth the process and give practices expedited reimbursement.

Training and Education

The focus on value-based care rather than the fee-for-service model is growing. New approaches including ACOs, and bundled payments that reward service for quality over quantity. For providers acclimated to payment per service, this can take some adjustment. 

To further improve reimbursement rates, stay current on policy and industry changes. Optimize your claims submission process by incorporating reliable coding and billing procedures, attending training, and speaking with companies directly about their coding policies. Create a consistent documentation process that supports medical necessity through regular team training and audits. Billing teams must be up to date with coding changes. Use dynamic seminars and self-paced online learning. Encourage and reward achievements for continuing education. When identifying documentation issues and revenue loss triggers, your practice can implement targeted solutions and utilize customized training to fill education gaps.

Many medical professionals now choose to work with healthcare billing solutions partners that sanitize claims before submission. Investing in reliable RCM technology helps medical providers streamline administrative tasks, including document management, claim submission, and reimbursement follow-up.

Advanced Billing Technologies

Consider platforms that automate repetitive tasks and improve claim processing from patient registration to full payment. Choose partners and solutions that will allow you to customize your needs as they grow. Use built-in analytics to your advantage to offer insight into revenue cycle performance and opportunities. Incorporate streamlined systems to dispute appeals. Ensure your staff has the latest required criteria to effectively dispute claim rejections. Track common denials over time to identify policy change needs. Designate roles with payor leadership personnel, and build relationships focused on mutual alignment around reimbursements. Maintain open avenues to discuss and simplify policy terms. Regular audits and internal self-assessments help coding precision. Use audit findings to improve staff education and decrease workloads.

Technology Solutions

When overcoming reimbursement issues through enhanced efficiency, the right tools create smoother revenue cycles and improved financial forecasting. RCM systems centralize the billing process into one intuitive platform. Automation reduces time-intensive manual work, and built-in checks reduce costly claim errors. Staff stays in tune with real-time dashboards and analytics that offer time-saving information.

Data analytics tools offer your practice a comprehensive view of your financial landscape regarding healthcare reimbursement by identifying practice patterns and areas needing improvement. By viewing data-driven insights as an advantage, healthcare organizations can make better decisions, optimize billing strategies, and improve overall financial efficiency. Identifying trends creates a space to develop proactive measures, leading to a more resilient and adaptive reimbursement process.

Future Trends

As healthcare continues to evolve, innovations in reimbursement best practices, technology, and collaborative initiatives will continue to improve. The path to clean and timely reimbursement will involve making some changes, but using the right combination of documentation, staff, and technology can safeguard your practice’s finances. Excellent RCM solutions partners have the tools to digitize workflows, automate tasks, and upgrade solutions. Healthcare administrators can take advantage of these changing trends and should remain open to resources that boost revenue. Virtual OfficeWare excels in guidance and technologies to help your practice overcome common reimbursement issues. Don’t let today’s healthcare reimbursement issues jeopardize tomorrow’s growth. Ensure you have the right solutions to keep your practice thriving. If you’d like to understand more about RCM services, contact us or schedule a demo today!