Why Is Medical Billing So Complex?
Medical billing sucks because insurance companies suck. It is just that simple. In fact, the entire economic model of insurance sucks:
Consumer pays a Premium. Insurance Company prices said premium ideally based on the probability of events occurring in the pool of Consumers. Consumers are then paid out from the pool upon filling a Claim once an event occurs.
What if the system is so complicated no one can tell how much they should be paid out? What if the system is so time-intensive/complex for filing claims that claims don’t get paid sometimes?
1 – The consumer loses money in the form of Premiums and bad bills when Claims aren’t paid.
2 – Claimants (doctors/patients etc. in this case) lose money as the Claims get underpaid or even worse, not paid at all.
3 – Gee who was the third group in this equation? Oh, that’s right…the insurance company…who keeps all that cash. I guess that’s how they can afford to pay their CEOs 8 figure salaries?
OK, mic drop 🎤
🗣️ Rant over.
What does that mean for medical billing?
1- You’re working in a healthcare insurance system where it can be, and will be, hard/not fun/stressful/anxiety provoking/____________________ <— insert dysphemism here.
2 – You’re working in a software system that is built partially for billing, not for billing, and/or was designed on MS-DOS and requires the “run” command to start up. Do you know what Oregon Trail is? If not, ignore the last comment. You won’t get it. Also, take a break from binge-watching The Handmaids Tale, or whatever, and go waste your weekend here for nostalgia purposes, please and thank you.
3 – So, you need to develop tight workflows/systems with accountability measures/auditing to be successful.
This is where this article comes into play! We’ll touch on delays in payment, legal issues, negative patient interactions, and problems with denials and other riveting topics in the medical billing process.
Failure to Capture Customer Information
Unfortunately, this is not that uncommon, especially in situations where the provider doesn’t own the patient data intake stream. What in tarnation is the “patient data intake stream?” ERs, where patients are too busy hurting/bleeding/etc. to concentrate on giving the right info. Radiology services, where the data comes from the referring physician…same as labs/anesthesia services, etc. So make sure you get the right info if you’re in control of the process. If you don’t, you will get denials and you may lose money.
The take-home: Junk in, junk out.
How to fix it?
Newsflash – your front desk is the busiest place in your whole office, which requires the most multitasking and pivoting…which is scientifically proven to hurt your brain and make you think less good (scientifically speaking)…oh and this is probably the lowest paying role in your office (I guess that’s why they always leave for greener pastures?!).
GIVE THEM TOOLS. Leverage the patient portal. No, not just turn it on…make your patients use it so they can pre-register. Now the desk can answer the question “is this right”?” Not “what is this?”
Set up workflows to confirm you have accurate demographics every 3-6 months. Paperwork, use your portal, use your patient engagement system…whatever. Again, now the front desk answers the “is this right” question rather than “what is this” when the statement gets returned.
Run eligibility checks for all your patients…every week…before the patient hits the front door. Same concept.
Patient Benefits and Pre-Collection
Patients are not always (euphemism for never) aware of their responsibilities related to payment of services or payment of copays/coinsurance/deductible. Their insurance plan says it is their responsibility, but guess who’s fault it is if you don’t tell them about their plan that they signed up for and pay for every month?! That’s right, shame on you.
The take-home: More education, more better.
How to fix it?
It is all in the presentation folks! Guess what the difference is in these two scenarios:
1) “Hey Mr. Didntknow, you have a bill because you have a high deductible and your plan doesn’t cover the other thing we did. Pay up.”
2) “Hey Mrs. Doesknow, we ran your benefits ahead of surgery and it turns out that you have a high deductible and also your insurance doesn’t cover the other thing, would you like to pay out-of-pocket at our cash-pay discounted rate? You do? Thanks so much.”
You can be the hero or the villain here folks…but the hero gets paid and the villain gets a negative online review that Google won’t take down and you have to go pay extra for the bill that wasn’t paid to the experts to have it dealt with.
Check benefits and collect before surgery by educating your patient on their benefits “so they don’t get a surprise bill.” It feels a lot less like a pre-op shakedown and is far less surprising than a bill on the back end.
Hold a pre-op counseling meeting for major surgeries. No, the patient doesn’t read your paperwork. No, they don’t care that they signed it when they’re mad afterwords. Yes, they can still leave a negative review without repercussions.
Know the line between cosmetic and reconstructive <— This is for you MDs. Your word = gospel. So when you’re wrong, or you don’t know…patients hear what they want…and it usually isn’t what gets you paid.
Incorrect Medical Coding
Bad coding = bad billing. This is where any billing company should be worth its weight in CPT books. You can leave money on the table by missing info. You can overbill and spur an audit (audit = v v bad = no monies for like 6 months while you argue with the insurance company where they actually have leverage). You can cause denials. You can lose appeals. The list goes on
The take-home: Your coders don’t code…your entire team does.
How to fix it?
Oh, this one is easy. Call your friendly neighborhood Auctus Group representative. Get you a good coder. Self-care is important. You don’t have time to stress. We can handle it for you.
All joking aside, the big myth is that coders do the coding…but if your billers can’t code, they will make errors at charge entry, they won’t be able to tell if you’re paid appropriately, they won’t be able to appeal…the line between biller and coder isn’t that black/white. This is why we specialize…because there’s like 20K+ CPTs (probably more, I’m just too lazy to go look it up right now), 60K+ ICD-10s, hundreds of modifiers, over 300+ changes last year…like we’re not robots people and that’s a lot of stuff to cram in our brain holes. Less specialties = less codes = less combinations = more mastery.
It is shocking how much still gets done manually in the billing process. Like breathtakingly so to an elder-millennial and cardiac arrest inducing to the TikToking Gen-Zers out there (I just had to Google how to spell Tiktok…shit…I think I’m old). The industry is moving at a glacial pace towards technology and your amazing billing company probably has some awesome plugins for Patient RCM and/or denials/appeals management…but until we can get true RPA/AI (techspeak for make the compuper do it and welcome to the Matrix)…we need a ton of “human in the loop” (AKA humans do the stuff). And humans are humans so they make mistakes…it is inevitable. Couple that with disparate workflows in segregated systems without a centralized task manager…and you’ve got a bit of a hot mess. 💩 💩 💩
The take-home: Trust, but verify.
How to fix it?
AKA build process redundancy and quality assurance. AKA double-check it because people make mistakes. You need someone to check the work. You need to check a percentage of it on a specific timeline…and check more if you’re not at a reasonable/acceptable accuracy level. You need to track it to manage performance. You need a task manager with recurring tasks to enforce accountability. What we’re really trying to say is…
Stay Vigilant for These Problems
Ohhhhhhhhh, you didn’t think we were just going to spoon 🥄 feed you our secret sauce…did you? Your organization needs to take daily steps to avoid these common billing errors. Most of these problems can be addressed by utilizing a proper medical billing solution that tracks patient intake information, coding, denials, non-payment, accountability, and more. Sound like a pain in the arse? It is. Call us. We can do it for you.