The healthcare landscape is rapidly changing, and sitting with a front seat view is the hospital business office. The uncertainty of ICD-10, healthcare reform and changing reimbursement rates, payer rules, compliance regulations…it's a lot to take in. A business office needs to be adaptable and ready to make adjustments. With the advantage of evolving technology around claim submission and editing, that includes adjusting the roles of its personnel, namely the medical biller.
Let's look at a snapshot of how a medical biller once functioned. As claim submission is both complex and incredibly important to an organization's revenue, a biller was a fundamental, high-level position, requiring thorough understanding of complicated payer rules. He or she often needed to review each claim before it went out the door to ensure it was correct. This was the best defense against payer denials. However, there are many reasons this approach is ineffective:
- Efficiency. It's a slow process. A biller reviewing claims requires more hours, more FTE, and time taken away from other crucial tasks. Also, claim failures typically occur as a result of either coding or registration and have to be sent back to the respective department. Billers are often simply routing claim issues to other areas to review, basically being a middle-man resulting in claims being touched multiple times by different staff.
- Accuracy. It's impossible for a person to review each and every field of every claim without missing errors, which equals denied dollars and more time that must be spent on correcting and resubmitting claims.
- Risk. If you employ the best biller in the business, you are still taking a huge risk. The knowledge of payer rules, regulations and contracts leaves with this person should they ever move on.
Today, your claims system can be and should be handling your claim editing. Payer rules should be built right in to the system, ensuring claims go out correctly the first time. Time spent on the actual billing function should be minimal. So, what can you do with your billing staff?
- Reallocate. Billing staff can tackle more important issues, like tracking and analyzing denials and turning denial information into new edits.
- Reinvent. Many providers have implemented systems where claims are routed to the responsible area (coding, registration) depending on the edit, eliminating the need for the biller to be in the middle. Other providers are requiring billing staff be certified coders so that corrections can be made to claims without referring them to other departments for resolution.
- Reassess. If a biller is still reviewing every claim before it goes out the door, there's a problem with your technology. Your claim system should be able to identify and correct routine billing errors and scrub the claim. If it's not doing its job, it may be time to find a new system.
Compliance is another huge consideration. An organization needs to be aware of and track the changes being made by the biller handling the claims as a safeguard against non-compliance that could be costing reimbursement. If they are routine changes, they can be automated within your claims system.
The best defense against denials and the most effective way to increase cash and shorten the revenue cycle is to use your billing staff in new ways. The title of medical "Biller" implies heavy emphasis on billing, but today's billers really should be spending little time on billing - instead using their expertise to solve A/R issues and denials.
Visit www.efficientC.net to learn more about efficientC claims processing system.
