When deciding to enter into a physician partnership, it is beneficial to take actions to ensure you are going into business with a reputable and reliable individual. Starting a physician partnership is an exciting time, full of new challenges, shared vision, and celebrations of small successes. During the good times, keeping a relationship on solid ground while running a practice is easy. But what do you do when you do not agree, and the honeymoon period is over? Whether you are discontent with the level of effort of one partner over another or you suspect your physician partner of outright dishonesty, disputes are going to arise.

Unfortunately, there are physicians in a long standing medical practice partnership who are not satisfied with the status of the relationship. They may feel stuck, frustrated, angry...or all of these. They know they've been silent far too long, but just don't know what to do. Like many married couples, physician partners often disagree about money and how it should be allocated. Even the best of physician partnerships go through rough times. But what if your partnership has issues you think cannot be resolved? What can cause such a change in a relationship that started out with high hopes and good feelings? In this article we address some of the most common problems medical practice partnerships face and ideas for how to deal with them.

Working Through Physician Partnership Issues

Finding a physician partner may seem hard, but finding your rhythm with your partner is much harder. Just like any other relationship, a business relationship too has its fair share of ups and downs. No matter how strong your relationship is with your physician partner, disputes are bound to arise sooner or later. When physician partners are disputing, their quarrels tend to disrupt the daily operations of their practice. If they are not careful about keeping their disputes between themselves, it can result in the failure of their medical practice. Remember, a strong physician partnership is built on open communication. Meet on a regular basis so you can share grievances, review roles, provide constructive criticism, and discuss future plans for the growth or direction of your practice.

, a consultancy specializing in strategic healthcare initiatives for physician practices. His firm helps devise and implement strategies that will allow practices to remain competitive and solvent. E-mail him 

Articles

When physician partners are disputing, their quarrels tend to disrupt the daily operations of their practice. If they are not careful about keeping their disputes between themselves, it can result in the failure of their medical practice.

Working through physician partnership issues

The coronavirus pandemic has stretched practices to their limit, with increased patient demand and extra precautions putting even more strain on busy providers and their staff. While the primary focus remains on keeping patients healthy and safe, today’s providers are continually challenged with attending to the business side of their practice, too.

For many practices, improving their billing and collections procedures, and ensuring they get paid properly for their services, has remained top of mind this year, particularly as the industry evolves to value-based care. But credentialing–one of the fundamental aspects of revenue cycle management (RCM)–is often overlooked. If practices and providers are not credentialed by government and private payers, or they neglect to renew their credentials, RCM is stopped in its tracks. Without credentials, they cannot legally bill patients for services or collect revenue. It can take months to recover that revenue stream, with a very real risk of losing substantial income in the process.

RCM Credentialing: A Labor- and Time-Consuming Process

Credentialing—or the process of contracting with insurance companies and obtaining hospital and facility privileges–can take anywhere from 90 to 120 days; COVID-19 is putting more pressure on the process. Due to the pandemic, healthcare organizations have had to rapidly scale their provider networks to handle spikes in demand—but until they’re credentialed, those providers cannot start treating patients or submitting claims.

Most practices typically do not dedicate sufficient staff to this complex legal and regulatory process. The work required to manage this is considerable: each individual provider may need credentials for 25 or more payers, each of which has different requirements and renewal schedules. What’s worse, many practices may not even realize there’s a problem until denials come pouring in. Certain Remittance Advice Remark Codes (RARCs) and Claim Adjustment Reason Codes (CARCs) 

can signal that there are credentialing issues

. Then, it’s up to the staff to dig deeper with each payer to see if it’s a simple problem, such as an error in the provider’s identification code, or worse—lapsed or no credentials—and try to fix it quickly so claims can be approved and payments can be made.

Maintaining Key Performance Indicators for RCM

Lack of credentialing not only adds work for the staff, but it also negatively impacts practice key performance indicators (KPIs), such as:

 – The goal for time from submission to closing of a claim should be thirty days. But without proper credentials, this time can increase significantly. It could take up to 21 days just to get notification of claim denial, and during this time that provider could have seen hundreds more patients insured by this payer, whose claims will also be denied. Not only will it take more time to fix the denial, but several months could also pass before the provider is properly credentialed, resulting in the need to write off all the claims in question.

 – Ideally, practices will want to ensure at least 75% of all claims are completed within 60 days. Trying to correct credentialing issues can take much longer, with claims continuing to age during that time. By identifying credentialing issues early, and ensuring that renewal timeframes are met, practices can keep their claim aging KPI in check.

 – The goal of every practice should be to obtain reimbursement upon the first claim submission, since denied claims mean no revenue. Claims denied for credentialing are not clean. Ideally a practice strives to maintain a 90% or higher clean claim rate. But consider if your practice has credentialing issues with a major payer -- a significant number of claims will lead to additional work simply because credentialing was not up to date.

Staying Ahead of the Credentialing Process

Taking a proactive approach to credentialing is vital to the fiscal health of your practice, whether it’s reviewing new providers who were added to help with pandemic-related demand, or ensuring existing providers are still eligible to be reimbursed for the services they provide.

For new providers, make sure to take the appropriate steps to get them credentialed, which includes collecting information about contracting with desired government and private payer insurance companies and obtaining national provider identifier (NPI) numbers for the practice and clinicians. When the applications are completed, review the terms and rates of the contract, and negotiate any objectionable conditions.

Once they have been credentialed, it’s up to both the provider and your practice to ensure there are no lapses. Reminders should be set, using Outlook, Office 365 or other calendaring apps to complete recredentialing or revalidation in a timely manner. Most insurance companies will require these updates every few years. They can be very strict, not allowing for retroactive reauthorization, which could put claims at risk of non-payment.

Manage Cash-Handling at Your Medical Practice

Outsourcing Can Keep Credentialing on Track

Given the complexity and time demands associated with credentialing and managing claims, many small practices do not have the staff to keep up. In these cases, outsourcing these efforts to a third-party vendor can alleviate much of the burden.

These vendors can provide a variety of services from software to track the credentialing process to a holistic offering that includes helping practices obtain and maintain credentialing for all providers. Working with a third party that has expertise in the credentialing process can save significant time—condensing the process from 90 days to as few as 15. And it can save your practice money by having staff ready to handle the paperwork and claims denials, and ensuring that revenue streams continue uninterrupted.

In times like today’s global health crisis, it’s vital to ensure that providers’ credentials are up to date so they can continue providing the best care available to patients while maintaining the viability of the practice.

, a leading health information technology and services provider, 

 serves as senior director, Greenway Revenue Services. With more than 13 years of experience in the ambulatory EHR and practice management market, he oversees the daily billing operations of revenue services for customers, ensuring compliance with divisional established policies and protocols, adherence to government and insurance payer policies and assurance of customer conflict resolution. In addition to his daily responsibilities, he also leads the Patient Call Center and Patient Accounts Receivable teams at Greenway. 

Taking a proactive approach to credentialing is vital to the fiscal health of your practice. 

Best Practices for Optimizing Revenue Cycle Management: Why credentialing matters

Hari Prasad, CEO of Yosi Health, discusses whether or not practices should consider upsizing or downsizing after the pandemic and outlines some areas of consideration.

Videos

Whether or not practices should consider upsizing or downsizing after the pandemic 

Upsizing or downsizing a practice after the pandemic 

We continue our 2021 asset protection for physicians checklist, addressing both predictable, recurring risks and those that are timelier and more reactive to current events.

Despite earning relatively high incomes, physicians’ long-term wealth is not always predictable due to the wide variety of risks they face. Some of those risks are professional, some are personal and some are related to non-practice business risks, like investing in real estate or other active businesses. Our last installment was reactive to 

 including election-related violence and business disruption, related employment law and medical partnership legal issues, and the need to be proactive about addressing the risks of social media. This week we examine five specific defensive steps to take.

The single most common asset protection mistake is still the most basic; 

doing nothing to protect yourself before something happens.

 In many cases this happens because an individual has been so busy working and accumulating wealth that haven’t ever taken the time to add up their exposed assets and consider the time and effort that was required to acquire them and what the effect of losing them would be. Review the simple 

 I’ve previously provided as a starting point and add additional exposed assets based on your own fact pattern.

It’s important to consider all the issues that can threaten your wealth, not just medical malpractice. I’ve previously outlined some of the most predictable 

risks that many doctors face in list form

, please take a look at it, especially if you think that professional liability is your only serious risk, and consider anything else in your life that should be addressed now.

Crash Test Your Current Business and Personal Legal Planning

Unfortunately, most people don’t have a good handle on what legal planning they have and if that planning actually does everything they need it to until it is tested in crisis, when it’s usually too late to do anything about it. While you are most likely relying on the professional skill of your advisors for the effective drafting of specific documents, one easy way to understand the scope of what your planning actually covers is to walk through 

 of some very common issues. Your planning should cover those basics as a bare minimum and will show you where to need to ask questions or have some additional work done.

Dollar for dollar, some of the most cost effective, predictable asset protection planning you can do as a doctor is buying all the right kinds of insurance at the right coverage limits. I take pains here to be clear that you need a comprehensive insurance ‘program’, not just an insurance ‘policy’ and as a minimum your personal insurance coverage should include:

) that adequately replaces your minimum required monthly cashflow

Life insurance in an amount adequate to pay off debt and generate income for those you leave behind

Insure Yourself Against All Professional and Business Risks, Not Just Malpractice

Avoid shopping on price alone and ideally, work with an experienced, independent insurance agent thar can explain what the various polices do and do not cover and the specific coverage limits each provides. Beware of simple “yes or no” answers when you ask if you have 

including employment law liability coverage, data breach and cyber liability, 

 liability insurance and RAC audit insurance, among others.

In many cases physicians discover that they are un-insured or under-insured on these issues and only have a “rider” on their medical malpractice policy of $50 or $100K, when it should be seven figures. Finally, think (and insure) outside the walls of your practice. Many physicians are owners, investors, or promoters in businesses outside their medical practices and may have professional liability from those sources ranging from service on a hospital or other business or private foundation 

 to being the de facto CEO of a real estate investment company that owns an office building or some rental homes or a member of an LLC that owns a surgery center where she has a title like CMO, president, etc. All these issues require the same attention to detail.

, JD, has practiced law exclusively in the areas of asset protection, risk management and wealth preservation for the last 16 years. He helps protect a national client base with more than $5 billion in personal assets, including several thousand physicians. He is a contributing author to multiple books for physicians and a frequent medical conference speaker and CME presenter. Learn more at

2021 Physician’s Asset Protection Checklist - Part 2 

5 Ways to Thwart a Cyberattack on Your EHR

Time and money matter when it comes to preventing a cyberattack. If you don’t allocate enough time or resources to update software patches and updates to your EHR, your practice could be vulnerable, said Jim Kelton, managing principal at Costa Mesa, Calif.-based Altius Information Technologies.

Here are five ways to stop a cyber criminal from infiltrating your EHR.

5 Ways to Thwart Cyberattacks on Your EHR

, the Boston-based manufacturer of the MoMe® Kardia ambulatory cardiac monitoring platform. Long has over 20 years in the medical device industry and also has held management positions in both hospital-based radiology and non-invasive cardiology.

For years cardiologists have relied on traditional remote cardiac monitors. A legacy monitor either requires the patient to return the unit to the physician’s office or mail it back to a third-party service provider after a period of days and wait for results—sometimes delayed by weeks—while the third-party performs the diagnostic analysis. In a scenario where the monitor diagnosis eventually shows evidence that an arrhythmia has occurred, the delay puts the patient at risk. The delay also eliminates cardiologist control over the data review, timing, diagnosis, and care of the patient.

Now doctors can fit a patient with a device and get immediate and current full-disclosure data over a secure internet connection. If a patient remotely presses a button on the device or calls reporting experiencing symptoms, the cardiologist can quickly see the patient’s up-to-the-minute data on a cell phone, tablet, or PC and make a critical cardiac arrhythmia diagnosis instantly. This is a dramatic alternative to having a patient return the legacy cardiac monitor, to a third-party provider and wait on the results.

Gaining clinical adoption for any change is the biggest hurdle for cardiologists. Changing clinical workflow is very complex and difficult for a process that likes routine and repeatability. Deviation finds clinicians having to stop and explain “why” ─ and they don’t have time for that. Fitting into workflows or improving them is the battle cry for vendors. Yet even if you have a better workflow, the technology must work. The task: make a clinician’s job easier, provide a way to provide safe and effective care with less worry on the technology and more focus on the patient. Cardiologists want total control over the device, feedback, and diagnosis for patient outcomes. 

Electrophysiologist Michael Mazzini, MD, shared his cardiology practice’s experiences adding a full-disclosure remote monitoring device (RMD) to their testing protocol.

“One of the concerns that we initially had, especially in our busy, independent practice, was a potential disruption in workflow for our staff; however, it has been very easy to on-board people and has streamlined our workflow quite a bit. For example, if we have a patient who has never had any telemetry monitoring, we can start Holter monitoring, and if the Holter is nondiagnostic, we can transition them to event monitoring or MCT with just the click of a button. This has made things remarkably easy for the physicians and staff. It eliminates making a patient turn in an old unit to check out a different one or wait a period of time before they get a different unit.”

As a result of the COVID-19 pandemic, many families are encouraging and setting their older family members up with the connectivity and the devices they need to take advantage of a telehealth visit. In many cases the patient may be able to avoid a trip to the emergency room while a phone call or video call may direct the patient to visit the hospital immediately. 

In order to make telehealth accessible to everyone, we must implement connectivity for patients in urban, suburban, and rural areas. Finally, physicians must have the information they need which requires access to patient data in real-time—from monitoring devices, testing platforms, and laboratory systems.

Eliminating staff gossip at your practice

The future of cardiac patient care is in elimination of redundant processes experienced when using a third party to provide monitoring services—while providing real-time, fast diagnosis, and revolutionary cardiac arrythmia care.

Fortunately, practices are acknowledging that introducing technology alternatives is easier than anticipated and actually streamlines the process and enhances patient outcomes.

Enhance cardiac patient monitoring while streamlining practice workflow

: Today we are presenting our conversation with Steve Avery, president and chief client officer at 

—a company specializing in revenue cycle management—where we discuss the practice of 'surprise' or 'balance billing' and how practices can navigate this increasingly complex landscape.

Our conversation specifically addressed anesthesiology practices; however, the general takeaways should also be applicable to primary care solo and small group practices.

We began by discussing whether or not there are ways for practices to know ahead of time if a patient coming to their office is covered under a partnering insurance plan.

 Well, I guess the first thing is, I want to add a little perspective around that question. Just in the country, there are thousands of health insurance plans. And not every health insurance plan has prominence in every community. So, the average anesthesiology group working at community hospital may have about 30 to 40 health insurance plan-specific contracts. So, it's not out of the question that a patient could come to the hospital with an insurance policy, that's not one of the 30 to 40 plans that are under contract with the anesthesiology group.

For the providers that we work with, they're all very diligently working to have contracts in place with the insurance companies that are likely to have patients in the area. The answer to the question is that anesthesiologists may not always know if a patient is coming to the hospital that has an insurance policy that's under their contract. The situation can be further complicated by an unfortunate occurrence where the patient is coming to the emergency room to be treated and then straight to the operating room, very little may be known about the patient at that time, especially the type of health insurance that they may have; unfortunate, but it happens like that sometimes. So, you know, we don't always know ahead of time.

: If you are able to identify that a patient is not covered under a partnering insurance plan, you may be able to communicate this coverage discrepancy prior to performing services.

: Well, if you do know ahead of time, and there are certain times where we may get a tip off from the hospital, that patient's not covered under one of the insurance policies, the optimal situation is to reach out to the patient well ahead of the data surgery, and let them know that the provider doesn't have contract with their particular insurance company.

This gives the patient the opportunity to work with their surgeon to select another facility where the anesthesiologist does have a contract with their specific health insurance plan. So where you know ahead of time you can make, you could make alterations or change the location of the surgery just to make sure that the patient has the best outcome possible.

: Avery did provide three things that practices can do to ensure that a patient is prepared to meet the cost of your services.

: Yeah, I think there are really three things that they can do.

Its first, you know, work with the patient. Second work with the insurance company. Third, involve the patient where necessary to work with their own health insurance company to resolve any situation.

The patient needs to know what to expect. And really, communication is very key. They need to know what happens after the surgery and what financial impact this may have on them as a result of the procedure. So, what you have to do is tell them that you're going to work with them, try to ease their anxiety about the unknown. And many times insurance companies will work with the anesthesiologist to negotiate a more favorable reimbursement rate, that will reduce the financial impact on the patient. In the case of an emergency where the patient could not select the hospital, much less the anesthesiologist, the insurance company may offer rates and terms for the for the provider that really kind of mirror the reimbursement that a provider would normally receive if they were under contract for that particular insurance company.

: Beyond discussing payments with patients, balance billing has been cited as a negotiating factor for practices.

: Balance billing legislation really does more to complicate things for the anesthesiologist than it really resolves. In many states where legislation is in place, the insurance company sometimes has a negotiation advantage over the anesthesiologist. If the anesthesiologist does not have a contract, they're reimbursed usually at a very low reimbursement rate typical for that particular geography or not typical with average reimbursement rates for that geography. And then to complicated things they can't build a patient for any unreimbursed portions procedure.

If they do have a contract, then you know, complications occur when they try to go back and renegotiate any terms or any increase in reimbursement. It becomes less than likely, since the alternative is to have is to not have a contract, and really become a financial disadvantage in the marketplace. So, the question should be does the legislation benefit the patient? Or the insurance company? Maybe both. In many cases, it does not benefit the physician, they're now at a disadvantage in those in certain circumstances.

: So surprise billing generally complicate aspects of the treatment process for both the patient and physician or practice. Should this then be something that practices are actively attempting to suppress, or will it remain something that just occurs at the end of the treatment cycle?

: You know, I think they should, and practices should work to have contracts in place with all the insurance companies that are under contract with the hospital; mirror what they do. And many times, for groups, this is a contractual requirement. In order for the anesthesiologist to have a contract provides services at the hospital, they have to agree to have contracts with all of the insurance companies that are contracted by the hospital. I think it's also a matter of ethics, meaning providers should want the patient to have a positive experience when they're being taken care of. In short, they should want to help the patient medically and financially by helping them to navigate through what could be a very difficult situation.

: This may all come down to a question of reasonable costs – how then should practices be determining this reasonable cost?

: Well, anesthesiologists or any other practice for that matter are financial entities, and they need to provide market wages for the doctors and the supporting personnel that work for the practice.

The market really determines the wages in the in the area. They also determine the reimbursement for that provider in that particular mark. So sometimes, you know, when there's a political solution that tries to solve a specific problem, the market sometimes gets removed from the equation, just like in the surprise billing legislation. In this case, the provider becomes the one to suffer financially. If you let the market work, the anesthesiologist and the insurance company will in large part reach an agreement on what is reasonable reimbursement for the services they provide.

Podcasts

Physician's Practice® spoke with Steve Avery, president and chief client officer at Abeo, about the practice of surprise billing—a practice that can present complications for, patients, providers, and the practice as a whole.

Podcast: Surprise Billing in Your Practice

The pandemic has changed the way practices can manage their waiting rooms. In this clip from our discussion, Hari Prasad, CEO of Yosi Health, discusses some of these changes and new considerations.

Some of these changes and new considerations.

How the pandemic has affected the waiting room experience for physician practices

Matt Dickson is Vice President of Product, Strategy, and General Manager of Stericycle Communication Solutions. He is a versatile leader with strong operational management experience and expertise providing IT, product, and process solutions in the healthcare industry for nearly 25 years.

For information on Stericycle Communication Solutions, visit 

As the United States begins distribution of the COVID-19 vaccine, health systems are in the process of establishing their vaccination plans, and reports of chaotic scheduling are already making headlines. As provider organizations across the country struggle with the unprecedented operational and logistical challenges, some are even turning to popular consumer-grade platforms to facilitate patient communications and scheduling, opening themselves up for issues related to HIPAA compliance and patient privacy. There are also widespread reports of missed appointments resulting in wasted doses, and a lack of staff available to administer the vaccine appear to be contributing to a delayed and inefficient vaccine rollout. Cases are mounting while vaccines are sitting unused. Now is the time to implement a strategic plan.

It is crucial to effectively communicate the rollout process across all patient populations, bearing in mind that blanket communication does not resonate with everyone. The formula, however, is the same as any other patient engagement strategy: drive patient access, action, and adherence. Health systems will likely encounter some hesitancy from patients as they are surrounded by conflicting statements about the vaccine but becoming the voice of reason will help patients decipher factual information and block out the noise. As you begin your vaccine rollout plan, consider the following elements.

Become a Reliable Resource to Help Overcome Vaccine Hesitancy

It is important that the marketing department within a hospital or health system takes on the role of a trusted source for disseminating healthcare information and knowledge to the public. This also includes closely monitoring channels for misinformation that may falsely influence a patient’s opinion on the vaccine, the coronavirus disease or healthcare in general. Tailored patient communication is critical in establishing credibility during the pandemic, with patients likely to turn to the steadfast voice of their hospital or provider for guidance.

As a credible authority, hospitals and health systems can help patients who are confused or uncertain about where to find reliable information around the pandemic and COVID-19 vaccines. Health systems will also encounter those who are hesitant about receiving the vaccine. Providing trustworthy information helps patients feel more comfortable and knowledgeable when making vaccination decisions.

As the voice of reason, health systems should proactively provide current and easily digestible information on vaccine distribution and protocols, simultaneously reiterating its social distancing measures and precautions in place to keep patients safe.

Utilize Effective Patient Engagement Tools

Reaching patients during the pandemic and beyond happens via patient hotlines, online scheduling, virtual check-in and text reminders, and should be a combination of human interaction and online self-service. Using the same principles for the vaccine rollout will help to clearly and effectively communicate the step-by-step process to patients, capturing their attention and inducing action.

The vaccine will be distributed in phases prioritizing high risk adults, essential workers, and healthcare personnel. As an organization, it is important to ensure you’re able to provide screening questions online or by phone and target specific groups who are ready to schedule appointments. It’s also likely that patients and staff will have questions about the process. A dedicated COVID-19 vaccine hotline and an online chat to answer frequently asked questions will help people navigate the phases of the distribution and alleviate any concerns without placing an increased burden on internal resources

In the event the vaccine requires a booster after the first dose, you’ll want to remind all patients to return for a second dose. This may be in the form of a text, email, or phone call based on which channel will induce patient action for this important step.

Crisis Communications: Solutions for 5 top challenges

Health systems must also have a strong social media presence to break through the noise and dispel misinformation that users can obtain through social postings and other media. Marketing departments can’t control what is being said on Facebook groups or fringe conspiracy theory sites, for example, regarding misinformation about COVID-19 vaccines. However, they can certainly closely monitor activity on the health system’s social media pages, mentions, and comments to ensure all information and conversations are accurate. Health systems should act to empower patients to make informed decisions based on factual information.

Don’t Lose Sight of the Patient After the Vaccine is Given

The journey does not end once the patient is vaccinated. Conducting calls to check on the recipient’s well-being and symptoms after receiving the vaccine is highly recommended and will help foster a long-lasting relationship. You can also use this opportunity to remind the patient of their booster shot, or any other upcoming patient care needed. A positive patient experience will ensure your health system is top of mind should another health concern or appointment need arise.

Matt Dickson is Vice President of Product, Strategy, and General Manager of Stericycle Communication Solutions. He is a versatile leader with strong operational management experience and expertise providing IT, product, and process solutions in the healthcare industry for nearly 25 years. Find him on 

. For information on Stericycle Communication Solutions, visit 

Create a plan to drive patient access, action, and adherence.

Four essential components for your vaccine rollout strategy

Andria Jacobs is the chief operating officer for PCG Software and has more than 25 years’ experience in the healthcare industry, encompassing both administrative and clinical arenas. Prior to joining PCG, Ms. Jacobs was the administrative director, medical management for VertiHealth Administrators. Previously, she was an independent consultant in ambulatory care and practice management, where her clients have included hospitals, physician groups, and the University of California, Los Angeles

Say what you want about the Centers for Medicaid & Medicare Services (CMS), but the federal government has gotten really good at ferreting out waste, fraud, and abuse in claims.

In September, the U.S. Department of Justice announced its 

 and opioid enforcement action in history, which resulted in charges against 345 defendants and alleged fraud losses topping $6 billion. Those charged included more than 100 physicians, nurses or other licensed medical personnel, so there likely were many billers and coders among those indicted. Seventy-five percent of the claims were for telehealth visits, with $845 million related to substance abuse treatment centers and more than $806 million related to various other healthcare fraud and illegal opioid distribution.

The CMS Center for Program Integrity also announced the revocation of Medicare billing privileges for 256 medical professionals for alleged telemedicine fraud cases. That represents a record-breaking number of actions related to telehealth, the use of which skyrocketed during the global pandemic.

Practice Managers: How you can become better leaders

There’s no doubt about it: CMS has been playing hardball regarding claims, which should keep everyone honest while saving the federal government money.

Billers and coders play critical roles in patient care, making sure that claims are correct and properly submitted so the practice, ambulatory care center, rehab center, hospital, or other provider can be properly reimbursed. In order to do their jobs properly, billers and coders need the right software tools to check claims before they are submitted to payers to maximize reimbursement, to reduce the incidence of refiled claims and to protect both themselves and their employers from fraud charges.

Better claims processing = higher payments

Despite technological advances, the claims denial rate remains 

 in healthcare, averaging between 5%-10%. That might not sound like much, but consider a 10% denial rate multiplied by the number of patients seen by a practice each day. The result is thousands in potential claim losses per week.

Even if every claim is successfully reworked and resubmitted, that effort represents a significant outlay in time and personnel. The cost to resubmit a claim has been pegged at between $25-$45, and many medical practices just write that off—leaving significant money on the table.

And just because a claim is accepted, that’s no indicator it’s coded correctly or that it accurately represents the breadth and depth of a medical encounter. As many as 

 that providers submit contain errors that can impact payment. The error could be simple—a mismatched name—or more complicated, like improper patient types or missing/incorrect patient identifiers.

Claims software can prevent many of these errors by comparing claims against a huge database of various payers, procedures, adjustments, and other data to help billers and coders get it right the first time. Be sure to ask potential vendors how often the database is refreshed. Payers can adjust reimbursement rates daily, so you want to access the correct codes for a particular day of service.

Even before the COVID-19 pandemic gripped the nation, CMS declared a 

 in late January, a declaration that has been renewed multiple times. As a result, countless claim codes have been reclassified or reworked to reflect current circumstances and how patients access care. For example, the methods and reimbursements for telehealth visits were greatly expanded as remote medicine skyrocketed in early spring.

Medical providers who don’t keep up on the billing front are losing out.

Billing software is also important to protect providers from fraudulent billing practices. Interestingly, the 

 dates to the U.S. Civil War and was originally designed to prevent fraud in the delivery of supplies to Union troops.

As it relates to healthcare, the False Claims Act covers a variety of potential offenses, including upcoding, falsifying treatment plans or medical records to justify payment, misrepresenting patients or services, or incorrectly coding the location of services. Fines can be up to three times the disputed amount, plus as much as $22,000 per claim and possible criminal prosecution.

Even without malicious intent, miscoding claims is no laughing matter. A

published in 2019 shows a strong correlation between fraudulent claims and substandard patient care. The study found that patients treated by a provider later excluded from the Medicare program for fraud and abuse were between 14%-17% more likely to die than similar patients treated by other providers. Those who committed fraud or abuse against Medicare were linked to about 6,700 premature deaths in 2013 alone.

Other coding issues that can cause potential issues include the use of Modifier 25, which can be used to report an evaluation and management (E/M) service on the same day the physician provided another service for the patient, and Modifier 59, used for a distinct procedural service.

Billers and coders want to do their best to serve their employers and maximize reimbursements, so they need robust and frequently updated billing software. Such software can also help keep staff on the right side of the law.

Andria Jacobs is the chief operating officer for PCG Software and has more than 25 years’ experience in the healthcare industry, encompassing both administrative and clinical arenas. Prior to joining PCG, Ms. Jacobs was the administrative director, medical management for VertiHealth Administrators. Previously, she was an independent consultant in ambulatory care and practice management, where her clients have included hospitals, physician groups, and the University of California, Los Angeles.

CMS has been playing hardball regarding claims, which should keep everyone honest while saving the federal government money.