In today's world of ever changing reimbursement models, as well as the nearing implementation of ICD-10, physician practices need to approach the revenue cycle from both a proactive and reactive perspective. Practices need to evaluate their current revenue cycle to determine and address negative affects when ICD-10 is implemented.
The revenue cycle begins with the first contact from the patient. Education and training of the front-desk staff is paramount. Accurate demographic and coverage information needs to be obtained during the initial contact with the patient, either via phone or in person and then verified at each patient visit. Copays should be collected during the check-in process.
A proactive step that could save the patient and staff time during patient check in is to verify and communicate to the patient or responsible party the copay responsibilities prior to the office visit.
Preparing for Life After ICD 10
With the implementation of ICD-10 there may be additional steps required to ensure the proper codes are assigned for the visit and claims are not denied in error. Has your staff been trained in ICD-10? Coders and billers are not the only staff that will require training. The front-end staff of a practice needs an understanding of the code set as does pre-certifications, claims reconciliation, and appeals staff.
It is essential to review and evaluate claims denials. Compile a list of the denials, ordering them by largest impact on the practice. Create a schedule and plan to work from the most significant to least significant.
Conduct an analysis of the denials. Are there denials due to lack of medical necessity? Are claims denied for lack of support for the level of evaluation and management code assignment? Review the ICD-10 codes assigned for the visit to ensure accuracy. A review of the provider's documentation may reveal that there is an opportunity to work with the provider on improving his documentation to support all billing and to capture all pertinent diagnoses. Is there a need for a clinical documentation improvement program? Does the potential return on investment support the need for the expertise of a clinical documentation improvement professional?
If there is a significant amount of denials due to lack of pre-authorization or pre-certification review the current process, inquire: Were the correct ICD-10 codes assigned during the authorization process? A lack of understanding or education in both ICD-10 codes and the pre-authorization process may lead to an increase in denials. Additional education may be required.
Claims Reconciliation/Payer Contracts
On the back end, reconciliation of claims should be conducted. Is the practice being reimbursed per the language of the contract? Are the correct copays being collected by the front-office staff? Review the current payer contracts. Contact the payers to discuss the implementation of ICD-10 and any potential impact due to changes in code sets. It is best to hold these discussions now instead of taking a "wait and see" stance.