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Navigating the Complexities of Insurance Billing: Top 10 Tips for Successful Claims 

4 Mins read

In the ever-evolving landscape of healthcare, providing quality medical care is only one part of the equation. The administrative aspects, such as insurance billing, play a pivotal role in the success and sustainability of a healthcare practice. Whether you’re a primary care physician, a specialist, or an integrative healthcare provider, grappling with insurance billing is a reality that cannot be ignored. It’s not just about ensuring timely payments; it’s about ensuring the financial health of your practice.

In fact, recent data underscores the significance of mastering the art of billing. Shockingly, more than 15% of claims are denied, translating to millions of dollars in lost revenue for healthcare providers. Furthermore, the cost of reworking denied claims is estimated to cost providers $25 per reworked claim. The implications are clear – a firm grip on your billing processes is not only advisable but imperative for the growth and prosperity of your practice.

At Soundry, we recognize the challenges that healthcare providers face in the realm of billing. With our extensive experience in providing billing services and handling thousands of claims on behalf of practitioners, we’ve identified some of the most common pitfalls and invaluable tips across the revenue cycle. Here, we present the top 10 billing tips that can be the difference between an impediment and a catalyst for your practice’s success.

  1. Accurate Data Collection at Check-In: Often overlooked, accurate data entry during patient check-in is the foundation of a streamlined billing process. This seemingly basic step can have far-reaching consequences. Gathering comprehensive insurance and demographic information is not merely a bureaucratic requirement; it’s an assurance of proper billing and a deterrent against potential claim denials.
  2. Always Collect the Insurance Card Photo –  collecting a photo of the patient’s insurance card should not only be viewed as a best practice but rather a requirement. Surprisingly, crucial billing details are often found on the back, making it a critical piece of information. In particular, even if the patient is confident that their insurance details and card are exactly the same, a photo should always be collected.
  3. Know Your Insurance Contract: Insurance payer contracts can be intricate documents, but familiarity with their terms is vital. Understanding the nuances of reimbursement rates, covered services, and billing guidelines within each contract is a safeguard against underpayment and denials. Billing for treatments permitted by your license but not by a specific insurance contract can lead to avoidable complications.
  4. Avoid Coding Symptoms: Precision in coding is more than just a formality; it’s a pivotal factor in the billing process. Rather than relying on symptoms as primary codes, ensure that appropriate diagnosis codes are used. Insurance companies mandate specific diagnoses for accurate reimbursement. Primary care providers sometimes make the error of coding symptoms, which can lead to confusion and, consequently, claim denials.
  5. Build a Denials Cadence: Don’t allow denied claims to accumulate in accounts receivable. Incorporating denials management into your weekly claims processing routine, rather than relying on less frequent batching processes, is a recommended approach. Neglecting this aspect can have severe financial ramifications and erode revenue streams. Proactively address denied claims by analyzing patterns, rectifying errors promptly, and resubmitting claims accurately.
  6. Always Call the Payer for Denials: The first time you see a particular denial situation, a conversation should be triggered with the insurance payer to understand the reason and prevent recurrence. Always make sure to get a case number and you may have to continue calling the payer several times to get the claim and cause clarified.
  7. Be Ready for Audits: Insurance payers can conduct audits at any time and even if you haven’t faced an audit, the possibility looms. Thus, comprehensive medical records are more than compliance; they are your shield against audit risks and billing disputes. Thorough documentation not only fulfills insurance payer contract stipulations but also aligns with your responsibilities under your state healthcare practitioner license.
  8. Be Clear on Coordination of Benefits: Deftly handling secondary insurance claims necessitates a solid understanding of coordination of benefits (COB) procedures. Clear comprehension of primary insurance, coordination intricacies, and adherence to proper filing protocols are crucial. Claims can get entangled in COB complexities, often requiring patient intervention to determine primary vs. secondary insurance. Secondary payers might even require physical documentation of primary claim rejection, further complicating the process.
  9. Adhere Strictly to Medicare’s Guidelines: Adhering to Medicare’s Local Coverage Determinations (LCDs) is non-negotiable. Deviating from these guidelines can lead to denied claims and financial penalties. Identifying your Medicare provider type – Par, Non-Par, or Non-Participating – and having access to your Provider Transaction Number (PTAN) are fundamental to successful Medicare billing.
  10. Access Insurance Portals Frequently: Embracing technology is crucial in modern healthcare management. Ensuring access to the online portals of all insurance providers you collaborate with is a smart move. This access streamlines claim tracking, eligibility verification, and communication. Access usually also means you have sign up for EFTs and direct deposits – ensuring that you get paid quickly. While it’s necessary to grant access to your billing and front desk teams, retaining administrative control is equally important. Swiftly deactivating access for terminated employees safeguards sensitive information.

By implementing these insightful billing tips, you’re actively fostering the financial well-being of your primary care practice. Beyond reducing billing errors, these strategies enhance the overall patient experience. As you integrate these practices into your operations, you’re not just managing bills; you’re laying the groundwork for the growth and success of your practice.

Tina Hsiao is the COO of Soundry Health, an innovative EHR and billing platform. Prior to joining Soundry, she was Chief Operating Officer of WePay – an innovative payments company that was acquired by JP Morgan Chase. Tina graduated from Columbia University with a BA and an MBA from Harvard Business School.

Insurance billing stock image by everydayplus/Shutterstock

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