Author: R@road22

Effective medical coding is crucial for healthcare organizations to ensure accurate billing, reimbursement, and compliance with coding guidelines. However, certain common coding mistakes can have financial implications for the organization, and even be considered abuse or fraud based on the nature of the errors. Having a highly trained team of medical coders and billers can help you overcome these common errors that will cost your organisation. Here are some examples of coding mistakes:

Incorrect or Incomplete Coding: One of the most common mistakes is assigning incorrect or incomplete codes to medical procedures, diagnoses, or services. This can result in under-coding, leading to lost revenue, or overcoding, which can result in audits, penalties, or repayment demands.

Upcoding: Upcoding occurs when a higher-level code is used to bill for a service that does not meet the criteria for that level of complexity. It is an intentional practice to inflate reimbursement. Upcoding can lead to investigations, penalties, and reputation damage for the organization.

Unbundling: Unbundling involves billing separate codes for services that should be billed under a single comprehensive code. It can result in higher reimbursement, but it is considered fraudulent and can lead to audits and financial penalties.

Failure to Document Medical Necessity: Insufficient documentation of medical necessity can lead to claim denials or delays in reimbursement. It is important to have clear and detailed documentation supporting the need for the services or procedures provided.

Lack of Compliance with Coding Guidelines: Medical coding is governed by specific guidelines, such as those provided by the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS). Failing to comply with these guidelines can result in incorrect coding, billing errors, and potential legal consequences.

Ignoring Regular Coding Updates: Medical coding systems, such as ICD-10 and CPT, undergo regular updates and revisions. Failure to stay updated with the changes can lead to coding errors and noncompliance with current coding standards.

Inadequate Staff Training: Insufficient training of coding staff can lead to errors and inconsistencies in coding practices. Regular training and education on coding updates and guidelines are essential to ensure accurate and compliant coding.

Inconsistent Documentation Practices: Inconsistent documentation practices among healthcare providers can make it challenging for coders to accurately assign codes. Clear and standardized documentation guidelines should be established to support accurate coding.

To avoid these mistakes, healthcare organizations should invest in ongoing training for coding staff, ensure compliance with coding guidelines, implement effective documentation practices, and regularly audit coding processes to identify and rectify any coding errors or discrepancies or outsource the entire revenue cycle management and medical billing services to an experienced team with a high affirmation rate.

About Red Road
As a high-performing extended team for your healthcare organization, Red Road provides expert clinical back-end services to improve your business efficiency and to grow your profitability. We are committed to delivering high-quality, truly responsive solutions in a cost-effective manner.

Whether it’s home health medical coding services, clinical compliance reviews in the USA, or revenue cycle management, you get the highest standards of service at significant cost savings for your organization, eliminating the unnecessary and costly barriers (middle-men) to working directly with your clinical back office support solutions provider.

Give Your Healthcare Business The Power Of More.

In today’s increasingly complex healthcare environment, healthcare organizations’ medical coding can be a daunting task. Handling it in-house can be time consuming and expensive, as it requires highly trained staff with the expertise and resources to achieve high levels of accuracy, speed, and consistency. That is why many healthcare organizations are turning to outsourcing for their medical coding services and revenue cycle management. In this article, we will discuss the top reasons why healthcare organizations should outsource their medical coding services.

1. Increased Quality – Medical Coding And Billing Compliance. 

Medical coding is a complex and detail-oriented process that has different regulations and rules across various states. Although ICD-10 offers the required framework, different payors have various unstated and often evolving needs that only an experienced and up-to-date coder will be able to meet. Clean claims help in improving your company’s bottom line. At Red Road, we have a systematic approach to medical coding and billing that helps us achieve an average accuracy rate of 98%. We take care of the modifier compliances and local coverage determinants (LCDs). Our highly trained team is adept at avoiding the common medical coding errors that lead to incorrect billing, claim denials, and other issues.

2. Cost-effective 

Outsourcing medical coding services can be more cost-effective than hiring and maintaining an in-house team. Medical coders are expensive to hire, as they are required to have special training and are an in-demand position. By outsourcing, you can tap into a pool of well-trained professionals at a much lower cost.

According to AAPC, the average salary of a medical coder is around $52000 and the salary for certified medical coders is much higher.

3. No More Billing Errors

Outsourced medical billing teams work with experienced and qualified billers capable of handling a range of medical claims. Rigorous training, continuous process improvement, and a drive to achieve accuracy help in mitigating billing errors before claims submission, thereby reducing the rejection rates.

4. HIPAA Compliance & High Levels of Data Security

Medical coding is subject to various regulations and compliance requirements, such as HIPAA, ICD-10, and CPT codes. Companies dedicated to medical coding and other clinical back-office support services make large investments to protect clients’ data, which are stricter than the standards of many individual healthcare organization.  Patient Health Information (PHI) and Personal Identifiable Information (PII), as well as other sensitive information, are highly safeguarded and healthcare organizations can be assured of the highest level of data security. Additionally, they are up-to-date with regulations and can help providers ensure that they remain compliant.

5. Increased Revenue

Having an in-house team of RCM staff and medical coders requires an investment of time and resources to recruit, hire, train, and retain the staff.  By outsourcing the entire revenue cycle management process, providers can reduce these overhead expenses. Furthermore, an efficient and effective outsourced team with expert coders will help maximize your revenue with clean claims, and reduced denials.

6. Scalability

Outsourcing medical coding services allows healthcare providers to scale their coding needs up or down depending on demand. This can be particularly beneficial during seasonal fluctuations in patient volume.

7. Quality Audits At Every Stage

Process audits are conducted at every stage of the billing and coding process to ensure high-quality. These audits help in ensuring that no information is missed out from the patient treatment plans and that health records are checked for both legibility and completeness of information before coding. Secondary audits after coding are done with a checklist to ensure every piece of information is filled in before submission. And finally, after the bill’s claims have been processed, the records are compared and checked for payment completeness.

8. Improved Transparency and access to insights.

Experienced and reliable medical coding teams keep thorough records and will share timely reports of your healthcare facilities’ performances. You will have access to all the necessary insights into your organization’s revenue. These reports will serve to supplement any internal records you maintain, as the outsourced team will be highly meticulous and transparent. Think of it as an added advantage to your organization.

About Red Road

As a high-performing extended team for your healthcare organization,  Red Road provides expert clinical back-end services to improve your business efficiency and to grow your profitability. We are committed to delivering high-quality, truly responsive solutions in a cost-effective manner.

Whether it’s home health medical coding services, clinical compliance reviews, or revenue cycle management, you get the highest standards of service at significant cost savings for your organization, eliminating the unnecessary and costly barriers (middle-men) to working directly with your clinical back office support solutions provider.

Give Your Healthcare Business The Power Of More.

According to an analysis report of data released by CMS – approximately 18% of in-network claims were denied on average during the reporting period. The pressure to reduce claim denials is at a peak in the healthcare industry. Every healthcare organization wants to look at its claims process with granularity to reduce the rate of denials.

Achieving a higher rate of Clean Claims (claims approved in the first submission) helps set precedence for claim approval for your healthcare organization. Implementing the right strategy with effective vendor and outsourced service partners can help you improve your Clean Claims rate. At Red Road, we have a proven system to significantly raise the Claims Approval Rate or Affirmation Rate. This article discusses process improvements for better denials management.

Track Your Claims Journey: Every claim submitted is monitored regularly to ensure its accuracy and timeliness. Real-time tracking of claims through an efficient system is important in order to know the current status of the claim. When denied, your team can then address the issues with the claim and resubmit it within the set time frame. Thorough Claims Review Process To Identify Common Causes For Denials: Dedicated resources allocated to finding the most common causes for denials for your healthcare organization could set up a review checklist to verify before claims submission. Providers can then pinpoint the areas of billing processes that lead to these common causes and rectify them at their point of origin.

Review and Update Policies and Procedures: Regularly review and update policies and procedures to ensure that they are aligned with payor requirements and industry best practices.

Provide Adequate Training: Ensure that your team receives adequate training on medical coding and billing practices to minimize errors or work with an extended team of expert medical billing and coding services.

Utilize Technology: Utilize technology such as automated claim scrubbers, electronic health records, and billing software to help reduce errors and streamline the billing process.

Monitor Performance Metrics: Establish performance metrics to track denials and appeals, including denial rates, days in accounts receivable, and recovery rates.

Develop a Denials Management Plan: Develop a comprehensive denials management plan that outlines processes for handling denials and appeals, including tracking and reporting denials and developing corrective action plans.

Continuously Improve: Continuously monitor and improve the denials management process, using data and feedback to identify areas for improvement and implement changes.

About Red Road

As a high performing extended team for your healthcare organization, Red Road provides expert clinical back-end services to improve your business efficiency and to grow your profitability. We are committed to delivering high-quality, truly responsive solutions in a cost-effective manner.

Whether it's home health medical coding services, clinical compliance reviews in the USA, or revenue cycle management, you get the highest standards of service at significant cost savings for your organization, eliminating the unnecessary and costly barriers (middle-men) to working directly with your clinical back office support solutions provider.

Give Your Healthcare Business The Power Of More.

Protected Healthcare Information (PHI) is worth more than credit card information on the dark web because the data that PHI contained is more comprehensive, making it ideal for identity theft. This makes most healthcare organizations highly vulnerable to being targeted in cybersecurity attacks. And when attacked, many healthcare businesses prioritize retrieving patient records by paying the demanded ransom. Protecting your organization’s office and patient records to safeguard them from cyber-attacks should be a top priority.

You can safeguard your healthcare business from cyberattacks by following these 7 essential tips.

Protect Your Healthcare Business With These Essential Tips

1. Train your staff: One of the most effective ways to safeguard your healthcare organization from cyber attacks is to train your staff to recognize and respond to potential threats. Conduct regular training sessions that educate your employees on identifying suspicious emails, avoiding phishing scams, and maintaining secure passwords.
   
   
2. Implement strong access controls: Multi-factor authentication (MFA) is one of the best practices to secure your healthcare business’s patient records against unauthorized access. Further, security can be enhanced by limiting access to sensitive patient data only to authorized personnel. Implement robust password policies, two-factor authentication, and role-based access control to ensure that only authorized personnel can access patient data.
   
   
3. Use strong passwords: Make sure all passwords used in your healthcare practice are strong and unique. Avoid using easily guessed passwords such as “password123” or “admin.” A random mix of upper and lowercase letters, numbers, and symbols is best.
   
   
4. Keep software up to date: Regularly update all software used in your healthcare organization, including operating systems, applications, and security software. A good security patch management plan will help identify known vulnerabilities and manage them immediately.
   
   
5. Use encryption: Encryption protects sensitive data, such as patient health information. The best practice to follow is to encrypt data both when it is stored and when it is transmitted.
   
   
6. Backup regularly: Regularly back up all important data to protect against data loss from cyber attacks. Make sure backups are stored securely and away from your primary systems.
   
   
7. Have a response plan: Develop a plan for responding to cyber-attacks. This plan should include steps for identifying, containing, and mitigating the effects of an attack. It should also include procedures for notifying patients, law enforcement, and other relevant parties in the event of a breach. Regularly review and update your plan to ensure it remains effective.
   
   
8. Ensure the data security compliance of your partners: If you work with third-party vendors for RCM, medical coding, or compliance, ensure that they are HIPPA compliant with SOC2 Type 2 Certification.

The revenue cycle for a healthcare provider begins with the patient scheduling their appointment and ends when the payment for the services taken is cleared, by either the provider or the payor. In the interim period, many steps need to be completed accurately to avoid any delays in payment, which can hold back your practice financially. Coding errors, inefficient claim denial management, or data duplication are just a few examples of inefficiencies in your RCM. Efficient RCM can provide financial stability and improve profitability for your healthcare business. That said, many practices still need help to optimize their back-end operations and to keep their revenue cycles consistent.

Follow these RCM best practices or outsource the entire revenue cycle management to an extended team of highly trained professionals to improve your bottom line and cash flow.

Best Practices to improve your RCM

Empathetic Patient Care

Patients are at the center of your business as a healthcare provider, and improved patient relationship management will significantly optimize your RCM while building patient loyalty. Most patients need clarification and support when navigating the payment process. When staff walks them through the payment process and options with them and offers clear communication, patients are more likely to pay on time. Staff must be trained to provide value to their patients by walking them through the payment process and building positive relationships.

Enhanced Staff Training and Collaboration

Beyond investing in tools, you should invest in continually training your staff to use them effectively. Collaboration between staff is crucial to mitigate delays and keep your revenue cycle running like a well-oiled machine. For instance, billing and coding staff need seamless communication with the claims denial management person to handle the denials quickly.

Regular Process Audits & Updates

Having a process in place to handle issues as they arise and mitigate them before they become bottlenecks to payment reimbursement is critical to an efficient RCM. Claim denials are bound to happen, but a high rate of denials is undesirable and problematic for the continued success and growth of your business. Regular process audits can zero in on the reasons and work towards reducing the occurrences.

Implementing financial data analytics will equip you with data on various RCM processes. Data on process performance indicators, denials occurrences, and payment hold-ups will enable you to monitor the system in real-time. You’ll be able to identify areas of concern and take the appropriate corrective actions required to streamline the process.

Clarify the Patient’s Financial Responsibility Before Offering Services.

Healthcare businesses run the risk of never being fully reimbursed for their services. Your revenue cycle could come to a standstill or be delayed when patients do not pay for the services rendered, sometimes requiring additional staff for follow-up on payments. RCM can be optimized for patient collection by informing them beforehand of their financial responsibility, either by collecting their deductibles or discussing payment plans.

Ease of Payment for Patients

Paying medical bills can be a challenge for patients who want to pay but may require more flexibility in their payment structure. Easing the payment process with multiple ways to pay could serve to reduce delays in payment. You can make online bill payments available, such as contactless payment and mobile wallets. The easier you make it for patients to pay, the quicker you receive full payment for services rendered.

Checking Insurance Pre-authorization and Eligibility 

Almost all Medicare patients need insurance pre-authorization. Ensuring you have a process to check for coverage eligibility and insurance verification will help optimize bill payments. As a healthcare provider, overlooking this aspect of RCM process could lead to unpaid bills.

Timely Claims Filing

As a healthcare provider, you need to file claims on time before deadlines for full reimbursement. Medicare allows an entire year for filing claims, whereas private insurers only give a 90-day deadline. If you miss the deadline, then your claims remain unpaid.

Improve Claims Denial Management.

Inefficient RCM can result in more claims denials, resulting in a need to implement a sound strategy to address claims as they occur. Whether it’s errors in billing or coding, lack of coverage eligibility, or issues with pre-authorization, your revenue cycle will need a more efficient process. Denials correlate to unpaid bills or lost revenue, and follow-up with each denial costs extra time and resources.

Visit www.redroadhbs.com

The decision to outsource Revenue Cycle Management (RCM) or keep the process in-house is one that will have a profound effect on your business. RCM plays a major role in determining one’s business’s cash flow and ensuring quality documentation and compliance is critical to patient care and payor compliance, making it important for one to invest time and thought into this decision.

Though both methods have proven successful for many healthcare businesses, what you choose should be based on a variety of factors such as the age and size of your business, the costs involved in running it, and what you envision for the future growth of your healthcare organization. While outsourcing can be cheaper and more efficient, in-house resources can typically give you more direct control over day-to-day operations. Understanding both of these methods and their pros and cons can help you decide which method works best for your business.

In-house RCM:

Cons

• Rising costs: Costs pertaining to software, staff training for any technology, regulations, employee salaries and benefits, computers and any hardware, and other office equipment extras are always on the rise, which can be quite exhausting for you while running your business.
• Support issues: Hiring a large number of billers as in-house personnel can be costly. Moreover, if your team is small and even one member goes on leave, it can cause problems.
• Development and training: Staff must be trained regularly to keep them up-to-date on any regulatory changes, technological changes, software upgrades, and so on. This can become a losing sum game, as it takes up time, money, and other resources.

Pros

• Direct control over RCM: You have direct control and oversight over financial procedures when medical billing is done in-house. Any billing adjustments you make can be executed immediately. Keeping track of your business’s finances in person can help you be more accountable and transparent.
• Monitoring and controlling abilities: In-house billing allows you to have complete control over your financial transactions. Also, staff accountability and openness are aided by working in-house.
• Confidentiality of your patients: In-house billing allows for greater control over patient records, which is critical for maintaining patient confidentiality.

Outsourcing RCM

Cons

• Fluctuating prices: The majority of billing organizations take a portion of the revenue they collect so the more money your organization makes, the more money you’ll have to pay.
• Limits access to data: It’s possible that you may not have access to all of your patient collections or the opportunity to see billing reports.
• Inappropriate and non-compliant security protocol: Outsourcing your RCM with the wrong outsourcing organization could put you at risk of a HIPAA privacy and security breach. Unauthorized disclosure of PHI, whether deliberate or unintentional, violates HIPAA security guidelines.

Pros

• Less expensive: Billing in-house necessitates office space, technical support, and a dedicated team. Outsourced medical billing, on the other hand, means that the outsourcing organization of your choice bears all these costs, making the process less expensive for you.
• Productivity: Many healthcare companies simply do not have the time to hire, train, and manage RCM coding and billing staff. They’re already overworked taking care of their patients and completing other administrative responsibilities. In such scenarios, outsourcing your RCM can be very much beneficial for your business.
• Keeping records is easier: When billing is outsourced, they keep insurance claim e-reports on a weekly, monthly, and annual basis. This frequent update ensures accurate billing and documentation.

Why Red Road is the RCM solution provider you need.

The healthcare industry is currently dealing with rising regulatory compliance obligations and decreasing bottom lines. As a result, if you chose the right RCM outsourcing organization, it is becoming preferable for your organization to opt for outsourcing RCM. Outsourcing to experts is ideal in order to stay ahead of your competitors and meet the expanding demands of the healthcare industry.

At Red Road, we can show you how to create an integrated outsourcing approach to extend the value of your healthcare organization and assist your teams in focusing more on the truly important drivers for your business and patient outcomes. Red Road is HIPAA-compliant and SOC 2 Type 2 certified, so we are equipped to tackle all of your back-end healthcare business needs and requirements without compromising the security of your data. This allows us to help ensure that your RCM needs are met without any audit risk. We also offer a transparent working environment, which will give you access to data whenever you need it and ensure that you feel like our team is simply an extended part of yours.

Dementia is a growing health concern due to the aging baby boomer generation. In response to this increasing healthcare burden, CMS is seeking more detailed information on dementia severity and associated behavioral disorders which are likely to support improvements in clinical care and to identify levels of expenditure.

The FY 2023 ICD-10 updates are now in effect, which means therapists and interdisciplinary teams should take note of the added specificity. The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government’s Department of Health and Human Services (DHHS), have provided the necessary guidelines for coding and reporting using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).

The 2023 ICD-10 code set now includes 89 new codes, out of which 69 codes are related to dementia, allowing for the classification and reporting of conditions like vascular dementia (F01.5-F01.C4), dementia in other diseases (F02.8-F02.C4), and unspecified dementia (F03.9-F03.C4). The new guidelines for reporting dementia emphasize that providers must clearly document the severity of the patient’s condition. If the documentation is incomplete, the coder should default to unspecified dementia without a severity code. The updated guidelines also offer the instruction that, if a patient with dementia is admitted to an inpatient facility and gets worse during their stay, the coder should assign the highest severity level reported during the stay.

The ICD-10 Coordination and Maintenance Committee has also provided clarifications to help determine the dementia stage:

• Mild dementia: “Clearly evident functional impact on daily life, affecting mainly instrumental activities. No longer fully independent/requires occasional assistance with daily life activities.”
• Moderate dementia: “Extensive functional impact on daily life with impairment in basic activities. No longer independent and requires frequent assistance with daily life activities.”
• Severe dementia: “Clinical interview may not be possible. Complete dependency due to severe functional impact on daily life with impairment in basic activities, including basic self-care.”

As mentioned above, 89 new codes were added to Chapter 5 (Mental, Behavioral and Neurodevelopmental disorders [F01-F99]) of ICD-10-CM, including 69 new codes for dementia with and without psychological symptoms. The updated ICD-10-CM classifies dementia (categories F01, F02, and F03) on the basis of the etiology and severity (unspecified, mild, moderate, or severe).

• F01.5-, “Vascular dementia,” is being relabeled as “Vascular dementia, unspecified severity.” This will distinguish it from a long series of codes starting with F01.A- that describe specific levels of severity:
• F01.A- Vascular dementia, mild
• F01.B- Vascular dementia, moderate
• F01.C- Vascular dementia, severe.

In the F02.- and F03.- code families, similar revisions are being made:

• F02.8- will become “Dementia in other diseases classified elsewhere, unspecified severity” with the addition of F02.A- through F02.C- that describe specific levels of severity
• F03.9- will become “Unspecified dementia, unspecified severity” with the addition of F03.A- through F03.C- that describe specific levels of severity.

These new dementia codes were discussed during the ICD-10-CM Coordination and Maintenance Committee 2021 meetings in both March and September. The proposal stated: “Although codes exist for dementia without and with behavioral disturbances, there is a need for additional detail on other key associated disorders, particularly psychotic disorders, mood disorders, and anxiety.”

Outsourcing clinical compliance support to India is not a new

concept in the American business market. Recent market reports highlight that India already has a substantial market share, with over 44% of the outsourcing business in the world currently located in India, including healthcare outsourcing. With the increasing complications of home healthcare clinical compliance regulations and severe staff shortages, India is becoming a trustworthy partner for clinical compliance support.

Here are some of the benefits of outsourcing clinical compliance support directly to India:

– Significant Cost Savings

At some point in time, most healthcare organizations find themselves in a position that requires an investment in a comprehensive team of clinical compliance specialists. With that team comes the requirement to further invest in training, upgrading technology, and staff management and retention. Outsourcing clinical compliance reviews directly to India enables healthcare organizations to process error-free claims, increase the percentage of charts reviewed, and reduce audit risk, all without requiring a significant cost investment.

– No Language Barrier

Many people may have concerns about a language barrier when working with companies in India. However, competency in the English language is essential in India when working with companies that have clients overseas, including those that deal with back-end clinical support services such as compliance, coding, and RCM. This English language requirement eliminates the communication gap when working with outsourced clinical compliance support companies.

– Rapid Turnaround Time

The turnaround time of Indian outsourcing teams is highly favorable to US companies. Due to the time difference, Indian clinical compliance teams work during the night in the US. With an average turnaround time of 12 to 14 hours, this means the charts are available for healthcare teams the next day when they come into the office. This helps healthcare companies to file their claims and ensure documentation compliance without delay.

– High Standards of Compliance

Qualified and experienced clinical back-office support companies in India are both HIPPA and GDPR compliant, as well as SOC2 Type 2 certified. These certifications help healthcare organizations evaluate the competence and security protocols of clinical back-end support companies and feel confident that their patient data is protected.

– India is a Proven and Established Outsourcing Hub

India’s offshore healthcare professionals have gained experience in this field for more than a decade, making it easier to understand both the concerns and benefits of outsourcing. This ensures that healthcare organizations get the benefits of outsourcing at an affordable rate.

– India is Home to a Large Workforce

Outsourcing clinical support services to India is increasing in popularity because the country is home to many experienced RNs and ICD-10 coders who are well-versed with international laws and will dedicate their time and efforts to keeping your documents organized and in compliance with the latest regulatory requirements. This large workforce enables outsourcers to recruit qualified RNs and ICD- 10 coders more quickly and easily than in the US, where there is currently a nursing shortage.

– Stable Government conditions India has consistently maintained stable governments and favorable offshore working policies, making it easier for American companies to sustain long-lasting partnerships.