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Revenue Cycle Management Medical Billing: Why Am I Not Getting Paid?

By: Phallynn Espinoza 

Your practice works tirelessly to serve patients, but it also needs to collect revenue. And there’s nothing more frustrating than long AR cycles and claims denials, both of which hit your bottom line.  

But the causes of slow revenue cycles aren’t without order; there are patterns. And once you understand the patterns, you can fix them. Here are the most common revenue cycle management medical billing issues I see, and practical solutions for improving them.  

Revenue cycle management medical billing and five common coding errors   

We’ve all been there before. You submit a claim, and that claim sits for a period of time and then gets kicked back with a denial. The challenge is that for many practices, this isn’t happening with just an occasional claim; it’s far too many. And once that denial comes back, staff have to go through the onerous task of resubmitting it to get paid, costing time, resources and – you guessed it – money.  

But let’s rewind: Why didn’t you get paid? 

There could be many reasons, but these are the most frequent:  

  1. Simple keying errors. Miskeying information is one of the more obvious reasons for denial, but I mention it because it’s very common. Busy coders accidentally enter the incorrect code, sending it on the path to potential denial. 
  2. Missing documentation. Payers often have rules around what documentation is required to accompany a claim, such as an X-ray, a lab test or something else. Missing documentation can trigger claims denials and slow down the revenue cycle. 
  3. Not keeping up with coding changes. Payers might make changes, such as the need to bundle certain services, and if coders aren’t up to date, it can also result in a dreaded denial. 
  4. Undercoding and overcoding. Most practices know that overcoding puts a claim at risk for denial and/or an audit. But something I frequently see is undercoding. Some practices are anxious about payer audits, so to “play it safe,” they under code visits, resulting in revenue losses that can add up. Interestingly, overcoding and undercoding can result in an audit, so recapture lost revenue by ensuring correct coding for every visit.
  5. Partially incorrect coding. Your team may have correctly coded one part of a claim but incorrectly coded another part. The result is only part of the claim gets paid. And here’s where I see things go wrong for revenue: the incorrectly coded part is written off instead of being resubmitted. These small losses add up over time and can adversely impact your revenue cycle. 

Knowledge is the first step: knowing where revenue is leaking from your practice. And the second step is understanding how to fix those leaks with best practices in revenue cycle management 

Revenue cycle management best practices 

The above challenges can be broken into a few core areas: insufficient staff, training issues and accuracy problems.  

There’s an ongoing talent shortage, and it’s often hard to find the right people with the right skills to help solve some of these revenue problems.  

For example, you might have a really strong coder who can post charges and payments, but you need someone to do the “in-between” tasks such as reworking claims, reviewing denials, and calling and sitting on the phone with insurance companies.  

Identify your gaps, and then create a targeted strategy to fill these gaps. That strategy might include outsourcing the in-between tasks and letting your internal team work on the higher-level tasks. And it might include plugging in some technology to improve workflows and help with accuracy.

Software can help improve accuracy on the front end so you can have less work – and less potential revenue loss – on the back end. And, software with machine learning can suggest codes for the visit when providers input their notes, helping mitigate potential coding errors.  

As you consider revenue cycle management medical billing and the future, you’ll likely continue to face ongoing challenges, like rising operating costs and talent shortages. However, by targeting your trouble areas with strategies to recapture revenue, you can more successfully navigate forward.  

Do you need help solving revenue cycle management medical billing challenges? Contact us and let’s have a conversation 

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