Billing and Collections

Don Rodden, president of the Healthcare Billing and Management Association, spoke recently with Healthcare Finance News Editor René Letourneau about the major billing issues currently confronting providers.

What major billing issues are facing healthcare providers in 2012?

Physicians and other providers are facing perpetual uncertainty, and there’s a downstream impact on many things. Revenue is declining in almost every specialty. Costs are continuously rising resulting in a margin squeeze.

Regulations are adding quality measures that take more time and more effort.

ICD-10 is another major billing issue facing us. It requires a tremendous amount of additional work to prepare and many providers have simply not started yet. Leaders in ICD-10 are very concerned.

Why haven’t providers done more to prepare for ICD-10?

They are in denial. It’s so big they almost don’t know where to start. It’s very complicated so it’s not easy to take the first step. But, taking that first step is the key.

Many payers are also not equipped to handle ICD-10. One complexity is payers feel they don’t have the resources to convert. The payer industry is trying to work around ICD-10 rather than complying with it. It will lead to claims denials.

Is it likely that enforcement of ICD-10 will be pushed back from the current Oct. 1, 2013, launch date?

CMS had developed a pattern of pushing back deadlines and deferring enforcement. However, industry leaders are all fairly certain there will not be a pushback on the Oct. 1, 2013, deadline. Enforcement may be another issue. But providers need to already have a master plan for how they are going to implement ICD-10.

Are you seeing a big uptick in providers moving toward upfront payment policies and in the use of patient predetermination software?

Many specialties do require an upfront payment. However, because of the administrative nuisance of determining a patient balance, many groups say it is not worth the time it takes. The payment predetermination tools have not caught on as quickly as might have been expected.

What advice do you have for providers as they try to increase their payment rates?

First, pay attention to the details in each element of the billing process. Are your payers paying you in accordance with your contract? Take the time to validate the approved amounts.

Second, automate your processes but keep in mind that automation has limits. It does not reduce the need to edit, reconcile and audit the process. You need a human being checking it and a process for validating that all the right things are happening. You need to work denied claims to their logical conclusion to make sure you are paid for all procedures you are eligible to bill for.

A third key point is that there needs to be a systematic review of policies and procedure. If you don’t do that, money can be lost. Things get old very quickly.