If you have ever worked in the healthcare sector, you know how chaotic and frustrating billing can be. It is not a straightforward matter and often comes with a lot of administrative headaches.
Data shows that billing disputes are no laughing matter as well. In fact, 30% of claims end up being denied for one reason or another. The administrative costs that come with appealing such cases can be as high as $118 per claim. A study by Change Healthcare showed that this added up to about $8.6 billion, which is both shocking and disappointing.
In this article, we will explore why medical billing can be so challenging and how healthcare facilities can adapt better.
What Makes Healthcare Billing Challenging?
To make matters worse, each state has its own way of doing things, which adds to the complexity. Filing for Medicaid reimbursement in a state like Texas can be a nightmare. Texas is one of the states that never expanded Medicaid to adults. You end up having some patients who can claim Medicaid reimbursement but not others.
The eligibility criteria in Texas are also more complex than in many other states. These include income and asset limits, along with factors like family size, disability status, and age, to name a few. In fact, it is partly the reason that options like TMHP billing solutions have become so popular.
If state laws were not a problem, there would still be many other challenges. For instance, dealing with coding systems such as ICD and CPT can be overwhelming. ICD-10-PCS has over 87,000 codes, and CPT has over 10,000. To make matters worse, these codes keep getting updated from time to time, making things a logistical nightmare.
On What Basis Do Rejections Occur?
Before we even begin to understand how to deal with billing challenges, we need to understand why they happen. Billing disputes happen for a wide variety of reasons, including:
1. Incorrect patient information
Healthcare professionals can only work with the information that they are given. If patients are careless and submit outdated or incorrect information, there is little that can be done. A single character mistake in a critical area like the policy number or date of birth can cause a denial.
There are some medical procedures that require the insurance company to give prior authorization. If this is not done before the patient undergoes the procedure, the claim is often rejected. Inadequate patient education ends up costing healthcare workers a lot of problems like this. Truth be told, it is a frustrating process for patients that does require reworking.
3. Coordination of benefit issues
If a patient has multiple insurance policies, it can often create a lot of confusion. Typically, the primary payer must be billed first, and only then is the secondary payer billed for the remaining costs. In the tension or chaos of a healthcare crisis, this is often forgotten.Â
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What Solutions Exist?
As we can see, patients themselves are often responsible for many of the billing challenges that occur. Even Millin Associates agrees that most recoupments and issues are due to human error and not fraud. Unfortunately, dealing with the situation requires more than just one approach. Let’s take a closer look.
Healthcare facilities will first need to ensure that staff training is at the best level they can afford. This means investing in extensive training for billing and coding staff. Naturally, a core part of this would include consciously keeping updated on billing policies and procedures.
The kind of technology a facility uses will also start to play a big role. Sadly, budget constraints make regular updating impossible. Healthcare professionals are often stuck using outdated programs instead of upgrading to more effective billing solutions. Finding open-source alternatives can be helpful, but they come with their own drawbacks as well.
Another area that can make things easier for healthcare facilities is patient education. Patients often come unprepared, with documents in a completely unorganized state. For instance, many are so uninformed that they get surprised by co-pays and out-of-pocket costs.
Outsourcing your billing requirements is also a good option in this regard. It can be particularly helpful if your requirements are too much to handle. Remember, it isn’t just the filing and sending of bills that is the problem. It is the invariable denials and disputes that need countering that end up being a mess.
Outsourcing the billing process can be one way to make things less stressful for your staff. They are experienced in ensuring that disputes rarely happen and can handle them effectively if they do occur. Yes, it does come with its own challenges, but it is still an option worth trying.Â
Conclusion
No one expects healthcare billing to be a cakewalk. The data you are dealing with is sensitive and should be handled carefully. That said, it shouldn’t be so complex that it ends up interfering with healthcare facility administrative work and patient satisfaction.
Thankfully, billing software solutions end up being lifesavers. It is unfortunate that healthcare facilities need to rely on solutions like this. Ideally, it should be the legislature that changes and adapts to make things easier. However, until that happens, healthcare professionals simply have to make do with the current tools available.
