7 Essential Principles For Growing Your Medical Coding & Billing Business

Introduction

The medical coding and billing industry is growing rapidly, owing to the advancements in new technologies. Creating and managing claims is where medical billing and coding interconnect and lay the foundation for efficient healthcare revenue cycle management.  In the U.S., medical coding is the creation of medical codes that identify specific diagnoses and services in the healthcare industry.

As the healthcare industry is predicted to double over the next ten years, medical billing and coding businesses are poised for growth, while being relatively recession-proof. Medical codes are applied using CPT®, ICD-10-CM, and HCPCS Level II classification systems. Medical coders, therefore, need to be proficient in the application of these codes. The medical billing business, subsequently, pursues the claims determined through these codes for reimbursements from health insurance companies to the healthcare company. A medical billing process, therefore, offers end-to-end billing and management solutions to ensure that the healthcare provider gets paid to their maximum entitlement. The ultimate goal is to minimize insurance claims denials.

If you are a healthcare provider looking to start a medical coding business or enhance your healthcare coding and billing solutions business, you must adopt certain modern tools, practices, and technologies to stay ahead and achieve lasting success. In this blog, we’ll walk you through the seven essential principles for growing your medical coding and billing business.

Role of Medical Coding and Billing in Healthcare

• Serving as a Means of Communication

Medical coding services are the means of communication between providers and payers and determine the reimbursement rules. 

• Managing Claims, Invoices, and Other Payments

With proper billing and coding systems in place, it is easier for the healthcare facility to manage insurance claims, invoices, and other payments. 

• Delivering Results with the Right Expertise

Every healthcare organization requires well-versed medical billers and coders to do the billing and coding for insurance and patient invoices. Since billing and coding services are intertwined, medical offices hire billing and lab coding services specialists with the expertise required to take on both responsibilities. 

• Regulating Patient Payments

The billing and coding process usually begins right after a patient makes an appointment with a healthcare organization or a medical office, as codes need to be entered and submitted to an insurer for pre-approval. This determines the patient’s out-of-pocket expenses, and the patient is charged that particular amount at the time of the visit.

Challenges for Physician Billing Companies

1. Changes to Healthcare Legislation

The healthcare industry is always changing and new legislation and regulations can significantly impact billing companies and clients. Billing companies should stay up-to-date on these changes and regulate their services accordingly. 

2. Rise in Competition

The medical billing industry is highly competitive, with many companies battling for market share. Billing companies have to work hard to stand out from the competition and get new business opportunities. 

3. Medical Billing and Coding Errors

Errors in medical billing and coding services lead to denied claims and payments, which adversely impact a billing company’s financial outcomes. Billing companies should invest in state-of-the-art technologies and training programs to improve the accuracy of billing processes. 

4. New Technological Advancements

New technological advancements are happening constantly in healthcare analytics and billing companies must stay ahead of the curve to sustain in the market. Investing in cutting-edge technologies such as AI and machine learning can improve the accuracy and operational efficiency of billing processes.

Benefits of Medical Coding and Billing

1. Improved Efficiency

Medical coding and billing can streamline your workflow and help reduce administrative burden.  Automated software and systems can help eliminate manual errors and save time, while also enhancing operational efficiency and productivity. For instance, you can use EHR/EMR systems to store and access patient data and leverage computer-assisted coding (CAC) to automatically generate codes without hassle. 

2. Increased Accuracy

Healthcare coding and billing systems ensure that your data is of high quality and consistency. It does the same for claims as well. To reduce the chances of under-coding, overcoding, or miscoding, healthcare providers must follow the official coding guidelines and standards. This will ensure that healthcare organizations don’t have to face denials, penalties, or audits. 

3. Reimbursement

Accurate coding ensures that healthcare providers receive the right reimbursement for the services provided to patients. Insurance companies and government healthcare programs use these codes and come up with the amount payable for each treatment procedure or service.

4. Increased Revenue

Medical coding solutions help you maximize your revenue and cash flow. All it requires is that healthcare professionals submit clean and accurate claims to reduce the chances of errors, penalties, or audits. Alternatively, this increases the prospect of being paid in full with quicker processes. You can use revenue cycle management software to track and manage your claims from submission to payment and use analytics tools to monitor and optimize your performance.

5. Compliance

Medical coding and billing ensure compliance with necessary legal and regulatory requirements. Only meticulous coding can help healthcare providers adhere to guidelines set by organizations like the Centers for Medicare and Medicaid Services. This is done to ensure compliance with all healthcare laws.

In-House Billing vs. Outsourced Medical Billing 

In-House Billing

• With in-house billing, healthcare providers have direct control over the entire billing process, managing them within the organization.
• For effective in-house billing, healthcare professionals invest in medical billing software, solidly built infrastructure, and technology that is handled efficiently. 
• It requires a highly proficient team of billing specialists, overseeing all the aspects of medical billing. 
• Selecting this option ensures a more personalized approach to medical billing, as the medical team has a better understanding of patient histories. 

Outsourced Medical Billing

• In outsourced medical billing, the billing responsibilities are shifted to an external partner, specifically an outsourced medical billing company.
•  These external medical billing companies are experts at rendering a broad spectrum of services from claim submission to coding. 
• They regularly follow up on unpaid claims and seamlessly manage all patient billing inquiries.
•  Selecting this option will help healthcare providers devote their focus primarily to patient care, assigning the labor-intensive elements of medical billing to seasoned professionals.

Principles  For Growing Your Medical Coding & Billing Business

Below are seven principles that can aid towards powering your medical billing and coding business to transform into an industry leader.

1. Computer Assisted Coding (CAC) is Your Best Friend

Whatever the state of the economy, citizens will always need medical care. However, the affordability is subjective. To avoid any dependence, medical billing services need to be increasingly efficient in their execution. The most error-free mechanism towards achieving this end is deploying the relevant technology, i.e., CAC. With the ICD 10 transition and the introduction of a host of new codes, medical coders need assistance in ensuring error-free coding. There are ever-evolving technologies of artificial intelligence and data mining that go a long way in improving medical billing management solutions, by predicting the possibility of insurance claims being denied, flagging faulty coding, and automating the coding process. Ultimately, CAC maximizes the amount that can be claimed by the healthcare provider, which is the key to retaining customers.

The use of CAC further reduces the amount of paperwork involved in the medical billing process. Technology has shifted the paradigm to automated coding, which limits the amount of manual execution and thereby minimizes the possibility of human error.

According to a report available through Research and Markets, “the global market for computer-assisted coding software is projected to reach $4.75 billion by 2022”. However, technology is not at a point where it can replace human coders. According to a recent report by Herzing University, “The U.S Department of Labor predicts that employment for health information technicians will grow by as much as 15 percent through 2024—much faster than average for most occupations.” This growth is significant of the ever-increasing need for innovative technology to be merged with the skill of medical coders and billers that will solidify the accuracy of medical billing claims services.

Further, according to the Capterra Medical Software blog, A Cleveland Clinic study found that CAC had a lower precision rate when used without the assistance of a credentialed coder. “It cannot be overemphasized that the use of computer-assisted coding alone does not replace certified coders. The software is limited and does not have the ability to apply guidelines or make decisions about code application and the circumstances of each admission. It does not have the ability to ‘choose’ a principal diagnosis or a principal procedure, and in many cases, does not have the ability to build ICD-10-PCS procedure codes.”

By Sandra L. Brewton (RHIT, CCS, CHCA, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer)

In a nutshell, CAC will assist your business through:

• Automated translation of clinical documents
• Suggested codes for application
• Flagged errors
• Automated reviews for coders
• Automated billing suggestions
• Fewer errors for swift claim acceptance

2. Embrace Blockchain Technology

To put it simply, blockchain technology is only a once-written record of digital scenarios that can be shared between different entities for viewing-only purposes. Within the healthcare industry, there is no doubt about the high level of interconnectedness between healthcare providers, medical billing and coding companies and insurance claims companies. This is where blockchain technology plays a crucial role.

According to a recent Forbes report of Forbes, “…it will be an evolutionary journey for blockchain-based healthcare systems or applications, where trust and governance within a blockchain network or consortium will be the critical success factors for implementation.” It further states, “The Hyperledger Foundation, an open-source global collaborative effort created to advance cross-industry blockchain technologies, is one great example among many developing small blockchain consortia models in the healthcare space.”

The main advantage of blockchain technology is its ability for data exchange, without the fear of data being hampered across entities. This maintains the critical standardization and security protocol of medical data.

A recent example of the implementation of blockchain applications is the development of a blockchain-based claims management solution with the collaboration of Gem Health and Capital One. This has considerably helped to reduce administrative costs and time wastage by providers and claims management companies.

Blockchain Technology can aid your business through:

• Higher standards of security
• Privacy protection
• Systematic and efficient information exchange
• Decreased hampering of medical data

3. Systematize Your Collection Unit

As a hindrance to effective revenue management, a considerable amount of time is spent on making collections of frauds and defaulters. This adversely affects cash flow. When the collection is purely manual, the ever-increasing paperwork and human time consumption take a huge toll on company profits. This process can be streamlined through a dedicated and small-sized team that is equipped with powerful and innovative technology to track and execute pending collections. Another strategy is to choose to pursue payments only when deemed necessary. This will reduce unnecessary time consumption. Well-trained and skilled staff is an essential prerequisite to an efficient practice management service and for efficient tracking and recording. Finally, outsourcing bad debt recovery, litigations related to accounts, etc. will go a long way toward inefficient utilization of company resources.

Collections of overdue amounts are the least likely ones to be reimbursed. This is probably the best reason that your collection team needs to be organized and avoid bad debts as much as possible. An active billing team followed by a small, but skilled collection team should be the priority within the medical claims billing service.

“many ASCs fail to implement a system of tracking and trending for these denials, which is, in his opinion, the most common mistake ASCs make when it comes to their billing practices. Typically, one or two employees perform all functions, and they expect that single person to be an expert in all of them. This rarely works. We typically see that they will excel at some but fail at others; a Jack of all trades is a master of none.”

– Brice Voithofer, VP, AdvantEdge Healthcare Solutions

To ensure minimum collection hassles:

• Keep the team small but skilled
• Avoid pursuing long overdue bills
• Implement a system to track the trend of denials

4. Distinguish between Appealed and Corrected Claims

This is the process that sets in when an initial claim to the payer is denied. Medical billers then appeal the claim or execute a corrected claim for reimbursement of the medical services. Every medical billing services company must be acutely aware of the difference between appealed and corrected claims since there are definitive and distinguished guidelines that set them both apart.

Claims that should be appealed are oftentimes sent as corrected claims and vice versa, which only further ensues denials. A corrected claim is submitted when the biller has identified that there was incorrect coding executed and rectifies it with the right pertaining code according to the CPT, ICD-9, and HCPCS codes initially billed. An appealed claim is one where the biller insists that the billed codes are accurate and provides the required evidence toward the same.

A skilled eye should make the distinction and then efficiently follow up with the corrected claim, if appropriate. In the case of an appealed claim, it is always wise to support the appeal with sufficient documentation that will minimize the possibility of denial.

“for a corrected claim, the appropriate changes should be made to the CPT, ICD-9, ICD-11 transition solutions, or HCPCS codes, and the bill type should be changed to reflect a corrected claim. Claim form 837 is typically used for corrected claims. If the bill type is not changed, it could be denied as a duplicate bill. The corrected claim should then be submitted electronically to ensure the quickest processing. However, for an appealed claim, you must supply documentation to support your appeal. Make sure to include the operative note, any relevant CCI edits, the invoice, the official letter of appeal, and a copy of the original claim. There are state-specific guidelines that can be used as well as payor-specific appeal processes.”

-By Dawn Waibel, DoP, Serbin Surgery Center Billing

The distinction between Appealed Vs. Corrected Claims ensures:

• No further rejection or denial of payments
• Speedy recovery of payments
• Higher customer satisfaction

5. Undertake Medical Coding Certification

These certifications are an assurance of standard compliance within the healthcare industry. These certificates are recognized across the country (by employers, doctors, physicians, medical insurance companies, and government entities) and add credibility to your business. Furthermore, the employees of the business must also be selected based on their certifications as medical coders.

According to the U.S. Bureau of Labor Statistics, “medical coding is one of the fastest growing professions in the nation.”

This profession requires skilled personnel to undertake the responsibility of medical billing and coding. The more proficient the coder, the less likelihood of coding errors and claim denials in the coding and billing process. Furthermore, Lisa Rock, president, and CEO of National Medical Billing Services says that the most common rejections are for invalid subscriber ID numbers; missing subscriber date of birth if different from the patient; invalid diagnosis code; and demographic errors, such as misspelled names.

There are several different types of certification within the medical billing and coding domain. They are as follows:

• Professional Coder Certification – This certificate determines the proficiency of the individual in the application of codes correctly of CPT®, HCPCS Level II procedure and supply codes, and ICD-10-CM diagnosis codes, which are useful for medical claims in a physician’s office.
• Outpatient Hospital/Facility Certification – This certificate confirms proficiency in the appropriate use of CPT®, HCPCS Level II procedure, and supply codes, and ICD-10-CM diagnosis codes in an outpatient hospital facility.
• Inpatient Hospital/Facility Certification – This certificate confirms proficiency in the appropriate use of ICD-10 transition diagnosis codes in an inpatient hospital facility.
• Risk Adjustment Certification – This certificate displays competence in the proper use of ICD-10-CM diagnosis codes toward risk adjustment in billing and coding.

Beyond the above, several individual certificates can be acquired, which display proficiency in specific types of coding.

Medical Coding and Billing Certification offers:

• Increased credibility
• Higher efficiency in the application of codes
• Better employee caliber
• Reduced rejection of claims

6. Invest in Business Intelligence for Consistent Improvement

The ever-increasing innovation in technologies suited for medical billing and coding has now brought data mining into the limelight as one of the most efficient ways to improve billing and collection services within the healthcare industry. From predictive analysis to prescription analysis, data mining creates reports that can go a long way in aiding intelligent decision-making and successful improvisations. Additionally, data mining offers automated, customized reports that can considerably reduce employee time and allow them to focus on more substantial areas of productivity. Finally, this is another way to minimize errors of coding and bill claims.

“MediGain’s proprietary medical billing solutions, which offer physician offices, ambulatory surgery centers, and hospital management a powerful healthcare data intelligence and reporting software tool that delivers control over clinical and financial data. Specifically designed for physicians, healthcare administrators, and billing professionals, our proprietary reporting process collects and aggregates data from all major practice management systems, electronic medical records and accounting software systems. The analysis is automated, eliminating the need for tedious and time-consuming manual analysis and reporting.”

-By MediGain

Data Mining can extend itself into the next billing and coding arenas:

• Accounts
• Payer Outcomes
• Profitability
• Patient Amounts
• Payments Details
• Demographics Analysis
• Quality and Outcomes

7. Identifying Skilled Coders

A healthcare career is complicated across the board. This holds for medical coders as well. Even though the job does not involve working directly with patients, it comes with a requirement to understand complex codes that represent a varied medical diagnosis.

“Coding is like learning a foreign language. What makes it difficult is that there are three major coding systems and each of them is different. So, you are learning three foreign languages.”- says Professor Bonnie Moore, RHIT and HIT program coordinator at Rasmussen College.

The challenge is in transitioning the medical diagnosis and identifying it with the relevant quote.

According to Meredith Kroll, clinic coder at Ridgeview Medical Center, “At times it was harder than I thought, particularly the E/M coding,” Kroll says. But she emphasizes that the challenging parts of learning medical coding are vital to later success on the job.” This emphasizes the need for medical coding and billing companies to take their time and hire skilled employees who are well-versed with the coding requirements. If at the initial stage, the coding is done efficiently, a lot of issues can be avoided along the way, such as rejections and denials. Another strategy for success is to ensure that your medical coders are keeping up with the changes in the coding requirements and the changing codes in the healthcare industry.

An efficient medical coder can:

• Increase business proficiency
• Identify related codes accurately
• Enhance revenue cycles
• Reduce the likelihood of denials and rejected claims

Conclusion

The medical billing and coding industry will grow significantly in the future, owing to the new advancements in technology and the growing demands of the healthcare industry. By implementing the principles and strategies mentioned above, healthcare companies can ensure more precision, enhanced efficiency, and more compliance with the regulatory bodies. This ultimately reduces claim denials, and enhances revenue cycles, ensuring that your position as an industry leader is maintained in the market. If you are looking to optimize your medical coding and billing business, get in touch with our experts at OSP.