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How to Refine Your Medical Claims Submissions

Providers over the last few months have experienced an immense shift in not only how and where they give treatment, but they have also had to navigate a decrease in overall patient volume. With elective surgeries being delayed due to the COVID-19 outbreak, refining revenue integrity during this unusual time is imperative for healthcare facilities. With new COVID-19 coding and billing practices, new documentation guidelines and the rapid ramp up of Telehealth care, the landscape for medical coders and billers is changing almost daily. It is more important than ever to ensure that charge capture is optimized and claims submissions are accurate to prevent rework costs and payment delays. Here are a few different readiness strategies providers can deploy to refine their medical claims submissions process, even with limited resources, in order to prepare for the healthcare industry recovery process.

Perform Charge Capture Audits

One of the best ways for providers to stay on top of compliance requirements and to ensure that accurate medical documentation is being done is to perform charge capture audits. Charge capture is the process providers use to get paid for services they delivered. Providers use detailed medical documentation to record care given to patients for encounters which are then assigned medical code sets. These codes are then translated into charges used to submit accurate and clean claims to payers. By performing regular charge capture audits, areas of weakness in the recording process, under-coding deficiencies and Electronic Health Record (EHR) technology challenges can be identified and addressed. Regular charge capture audits will not only optimize accuracy and patient safety, but will greatly reduce costly rework.

Build a Claims Editing Process

Payer requirements are becoming much more complex. With payer regulations constantly evolving, it is important that submitted claims are compliant to each payer’s unique business requirements. Signature Performance has a team of medical claims edit experts who make it a priority to not only stay on top of the latest coding and billing changes in healthcare, but who stay current on the latest payer requirements and industry trends. Even the smallest error or gap in technology can cause a claim to be rejected and can cause rework and expensive payment delays. Building and updating bridge routines require constant monitoring and modifications, which substantially improves first pass claim submissions. For one of our health system partners, our team recently implemented our claims editing process and they saw an increase in clean claims compliance go from 54% to 95%.

Establish a Cross-Functional Revenue Integrity Team

As part of optimizing revenue integrity for your organization, it’s important to establish a cross-functional team which consists of areas such as CDI, medical coding, billing and accounts management. This team fosters collaboration between the functional areas to review trends, discuss issues, exchange insights, develop process improvements and execute action plans. The ultimate goal is to preserve revenue integrity and assure strong financial performance.

Get Access to Claims Submission Expertise

More and more healthcare systems are finding that navigating the complexities of claims submission and all of the related revenue cycle functions to be overly cumbersome and driving up administrative costs. As part of the operational model, healthcare system leaders should consider working with an outside strategic partner. Strong financial performance takes the right resources that specialize and are highly knowledgeable in all aspects of the revenue cycle. The right partner brings economies of scale, optimizes technology investments, shares valuable insights and provides access to knowledgeable experts who ultimately drive reimbursements and reduce administrative costs.

We believe the healthcare system in the United States deserves only the best and that is what motivates our team to live our mission of reducing healthcare administrative costs for our clients. At Signature, our experience on both the payer and provider side of the business allows our dedicated team the opportunity to evaluate industry issues from a variety of perspectives, eliminate any static within communication efforts and create custom solutions that get to the core of some of the biggest problems facing the healthcare industry today.

To request more information about provider auditing, contact our team today!


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