Getting on the same page. Rowing in the same direction. Singing from the same songbook. Call it what you will, but teamwork is critical in all facets of healthcare.
While the importance of the patient/provider relationship is well known, the ties between medical billing coders and claims auditors are less familiar but equally critical to a facility’s financial health. The payer claims adjudication process has been slowing reimbursements, so submitting clean, properly coded claims the first time can increase revenues while reducing days in accounts receivable (A/R days).
In fact, according to MDaudit research, hospitals can retain approximately $150 million – $250 million by ensuring accurate coding and billing protocols – a huge difference at a time when hospitals are facing unprecedented profitability concerns.
Payers Taking Longer to Adjudicate Claims
Claim rejections continue to plague every aspect of the healthcare industry. According to MDaudit research:
- 12% of professional claims were initially rejected, with an average denial of $288, a 2% increase from the previous year.
- 26% of hospital outpatient claims faced first-time rejection, with an average claim value of $602, a 6% increase.
- 27% of hospital in-patient claims were rejected the first time, with an average value of $5,810, a 9.5% increase.
At the same time, the number of days between submitting a claim and the initial payer response has also been rising. Professional claims take 13 days to first response (+3 days from the previous year); outpatient claims take 15 days (+4 days); and inpatient claims require 16.5 days to first response (+6.5 days).
In each instance, slower payer response adds pressure on operational teams to help ensure claims are reimbursed on the first pass, making the relationship between medical billing coders and auditors a critical success factor.
Areas for Coding Improvement
In addition to the revenue impact, coding issues increase a hospital’s risk for external audits, which places a costly and unnecessary administrative burden on organizations with already limited staff resources. Based on MDaudit’s analysis of unsatisfactory audit findings, missing modifiers or modifiers inconsistent with the procedure code (34%) and charges not meeting qualifications for emergency/urgent care (22%) were the top reasons for hospital outpatient coding-related denials, while inpatient denials were led by payers deeming the information submitted as not supporting the level of service (37%).
The analysis also identified several areas offering the greatest opportunity for coding to help hospitals retain revenue, including:
- Ensuring secondary diagnosis is documented and billed
- Bundling and submit procedure codes appropriately
- Reporting drug unit utilization properly
- Attaching clinical documentation for diagnosis and treatment
- Ensuring proper modifiers are coded with documentation
While these are the types of improvements that can result from internal audit findings, it’s important to note that the auditing process isn’t meant to be a “gotcha” for coders and providers who make mistakes. Rather, it serves as a check on the claims process to ensure that the physician or other provider — or the facility itself – is maximizing the revenue it is entitled to based on the services provided to patients. That interchange between coder and auditor should take place in real time, if possible, to correct mistakes before they are submitted to payers.
In other words, a real-time review process can strengthen the relationship between coders and auditors while maximizing revenue.
Auditing Platform Enhances Auditor-Medical Billing Coder Communications
The auditing process should never be one way, from auditors to coders or providers. Rather, it should be a two-way street, with the proper give-and-take among professionals to arrive at the correct codes and charges that accurately reflect the medical visit, procedure, test, or equipment required.
A technology platform can facilitate real-time communications between auditors and coders, reviewing what went right, what went wrong, and what improvements can be made to claims that have not yet been submitted. Medical billing coders should also have an opportunity to disagree with an auditor’s findings, backing up their code selection by referencing the relevant documentation. This just-in-time communication improves the claims process, increasing first-time pass rates not only of the current claims, but also of similar claims in the future because coders and auditors are on the same page.
Teamwork between medical billing coders and auditors ensures revenue integrity. Eliminating manual workflows and streamlining processes wherever possible help coders and auditors concentrate on the important tasks at hand. A robust technology platform can help auditors uncover risk areas and identify coders who may need additional guidance. By using a central communications channel, coders and auditors can quickly work through issues to mitigate systemic billing compliance issues. Finally, a coder audit management tool allows full visibility into coder workloads and easily allows resource allocation.
Technology can facilitate the teamwork necessary to make the right coding decisions the first time to increase revenue and decrease A/R days.
Dig even deeper into how coders and auditors can learn to improve processes, and discover the trends that will dictate how you move forward this year in the Benchmark Report.
