Payers have created a mine field designed to keep as much of your money as possible without violating the law. It's an adversarial system without a win-win angle. It is in your best interest to understand the details of you're going to beat them at their own game.
Technology is the key to winning this game. You must have the best possible practice management and medical billing software functionality in place if you're going to receive timely payment for your claims.
Make sure your practice management and billing system can:
- scrub claims
- utilize a code wizard with E&M
- handle delinquent claims
- manage errors and rejections
Claims scrubbing functionality ensures that your claims are as "clean" as possible, which will mean fewer denials and faster payment. Your system should:
- For selected CPT codes, identify the applicable and mandatory modifiers
- Ensure that requirements for medical necessity are met by justifying the ICD-9 code to the CPT code
- Based on acuity and severity, sequence ICD-9 codes correctly
- Edit for ICD-9 codes that do not support a selected CPT code
Utilize a code wizard with E&M to assist the provider in coding at the right level
Studies show that providers consistently undercode to avoid non-compliance. A code wizard program will help the provider code appropriately, with confidence.
Handle delinquent claims
When a carrier doesn't respond to a submitted claim, there's a reason. Your system must have integrated or built in functionality to closely monitor the response period and notify your billing clerk when claims reach an age threshold (perferrably a user-defined age threshold so that you may control this function closely).
Errors and rejections
Errors and rejections must be handled quickly to speed claims payment. Your system must include the ability to track rejections and errors to facilitate fast resolution. and proper statement reporting to the guarantors.