Revenue Cycle Management
practice management, compliance and ClientFirstTM service.
Radiology has undergone a significant transformation in recent years thanks to the rise of precision medicine. This exciting healthcare field is changing the game by tailoring treatment plans to each patient’s needs.
Radiology uses advanced imaging to identify unique patient characteristics and develop targeted treatment plans. From early cancer detection to diagnosing rare genetic disorders, precision medicine is revolutionizing how we approach healthcare.
According to a recent Market Research Future (MRFR) report, the precision medicine market was valued at USD 65.93 billion in 2021 and will reach USD 157.46 billion approximately by 2030 at 11.9% CAGR during 2022-2030.
On the other hand, Data Bridge Market Research shows that the global radiology market was valued at USD 26.6 billion in 2021. This market field is expected to reach USD 43.04 billion by 2029, registering a CAGR of 6.20% during 2022-2029.
Additionally, this report added that North America dominates the radiology market. The region’s radiology market is growing due to high demand for digitization and increased awareness of advanced treatment benefits.
One of the most significant expansions of radiology lies within precision medicine. This area of medicine customizes treatment to a person’s unique genetic, environmental, and lifestyle factors.
The American College of Radiology states that precision medicine uses artificial intelligence (AI) to extract features from data to categorize biological entities into subpopulations to predict their biology, behavior, or response to specific treatments.
Learn more about AI and other relevant trends for your practice in our blog Four Technology Trends You Should Integrate Into Your Radiology Practice.
Radiology plays an essential role in precision medicine by providing imaging biomarkers that can help guide treatment decisions.
Overall, precision medicine significantly impacts the radiology field enabling radiologists to provide more accurate diagnoses, develop personalized treatment plans, and deliver more targeted therapies to patients.
Therefore, radiologists must stay on top of precision medicine updates as methods of diagnosing and treating diseases are ever-changing. Remaining up to date can ensure they provide the best possible care to their patients.
At AdvantEdge, we understand the importance of keeping up with radiology trends to maximize revenue collection, reduce workload and ensure patient satisfaction.
To learn more about technology trends in radiology and how to make the most out of them, get in touch with an AdvantEdge expert or stay up to date on company and industry trends by visiting our Linkedin page.
As a medical provider, you must ensure that your business associates are HIPAA compliant. After all, your practice must protect the privacy and security of your patient’s protected health information (PHI).
Business associates perform functions that involve using or disclosing Protected Health Information (PHI). If they do not comply with HIPAA, eventually, it can put your patients’ PHI at risk and expose your practice to legal and financial penalties.
First, identify which business associates can access PHI. Then, conduct a risk assessment to determine the potential risks and vulnerabilities associated with their use and disclosure of PHI. This will help you identify areas where HIPAA compliance may be lacking.
Ensure you have a valid business associate agreement with each business associate. They must make sure they are following HIPAA guidelines. Also, your business should review the arrangements to ensure they are comprehensive and include all necessary HIPAA requirements regarding compliance, security measures, and breach notification procedures.
Request that your business associates provide you with evidence of their HIPAA compliance, such as a copy of their HIPAA policies and procedures, training materials, and documentation of their security protocols. Also, remember to ask them to update you on how they manage and safeguard your information.
Regularly audit your business associates to ensure they adhere to HIPAA obligations. For example, conduct on-site visits, review their policies and procedures frequently, and test their security measures. Remember to obtain proof that your associates provide HIPAA training and education to their staff. This will help them understand their obligations and ensure they handle PHI securely.
Medical practices must stay updated with the constantly evolving healthcare industry news, including potential HIPAA policy changes. Above all, make sure you know these changes, if any, and understand how these can impact your practice. This will help you detect areas of improvement on your HIPAA safeguards and establish new ones if pertinent.
By following these best practices, you can ensure that your business associates comply with HIPAA and that your patients’ PHI is protected.
At AdvantEdge, we are HIPAA-compliant. We have controls and safeguards in place to ensure the confidentiality, integrity, and availability of your PHI. Our employees are continually educated to be updated on HIPAA policy changes and avoid potential breaches.
To learn more about navigating our medical billing services, contact an AdvantEdge expert or stay updated on company and industry trends by visiting our LinkedIn page.
The radiology industry constantly evolves and develops new technology trends to improve physicians’ performance and ensure patient satisfaction. These industry trends can also facilitate radiologists’ tasks to allow them to focus on patients while ensuring proper revenue collection.
Radiology practices must stay on top of these latest trends in the industry to stay ahead of the competition. By understanding and implementing these trends, medical practices and professionals can:
Artificial Intelligence (AI) continues gaining traction in the healthcare industry in 2023, including radiology. AI uses algorithms and machine learning to analyze and interpret data, deliver personalized experiences, and automate repetitive tasks.
Learn more about AI in the healthcare industry in our blog 5 Healthcare Trends to Watch this 2023.
According to Radiology Business.com, AI will rapidly be deployed, especially across medical imaging to help techs and radiologists do more with less. This technology has come a long way in helping address physician burnout and radiologist staff shortages.
AI can speed-up exam throughput, improve quality images, auto-complete reports, automate measurements, and reduce retakes. Artificial intelligence will continue expanding in radiology; therefore, specialists must stay on top of this trend. This can help radiologists reduce workload, improve patient experience, and facilitate tasks.
Another key point is Magnetic resonance imaging (MRI). The National Institute of Biomedical Imaging and Bioengineering (NIH) states that MRI is a non-invasive imaging technology that produces three-dimensional detailed anatomical images.
Additionally, new MRI technologies can help drive MRI expansion in the coming years. New MRI specifically features automate and simplify the imaging process and enhance the patient experience.
According to Radiology Business.com, MRI is becoming more accessible and less expensive to maintain. Also, when artificial intelligence is integrated into MRI systems and post-processing software, AI helps set up protocols and simplify exams, speed up exam times, and implement imaging protocols in less time.
Medical billing automation is changing how radiologists are paid for their services. As a matter of fact, this automation allows technology to perform repetitive tasks automatically, more quickly, and with a lower margin of error.
Therefore, it is vital for medical practices wanting to eliminate human errors in claim submission, detect billing errors before filing claims, reduce denials, and guarantee that you get paid for your work.
With medical billing automation, radiology practices can:
Outsourcing your medical billing is another option to automate this process. If you outsource your billing, your RCM partner will provide you with billing specialists trained in billing automation to improve your claim processing and increase cash flow.
Read why you should consider outsourcing your medical billing in our blog Five Benefits to Outsourcing Your Medical Billing in 2022.
Medical practices’ IT and data security requirements differ significantly from other businesses. From interfaces to labs, and medical equipment to medical record data retention laws – it is critical to partner with a company specializing in outpatient healthcare.
Above all, healthcare-focused IT can offer you services regarding network installation and security, cybersecurity, software interfaces, backup procedures, and EHR hosting.
Counting on a healthcare-focused IT partner can significantly help your radiology practice stay up to date with industry regulations, enhance your processes, and protect your patient’s information.
At AdvantEdge, we understand the importance of staying on top of technology trends to maximize revenue collection, reduce workload and ensure patient satisfaction.
To learn more about technology trends in radiology and how to make the most out of them, get in touch with an AdvantEdge expert or stay up to date on company and industry trends by visiting our Linkedin page.
Every year brings new medical billing challenges for practices. If these challenges are not appropriately addressed, these can lead to an administrative burden, staff burnout, and delays in reimbursement.
Addressing these billing challenges effectively can help you:
The 2023 billing changes regarding the CMS Physician Fee Schedule and the CPT E/M codes changes demand that medical practices know these updates to bill for their services appropriately.
These changes are summed up by the lack of expertise of the billing staff and the struggle with technology adoption to improve billing processes as the primary billing challenges for practices this year.
Medical practices must be ready for new code and guideline changes regarding CPT Evaluation and Management (E/M) and the 2023 CY Physician Fee Schedule (PFS).
Coding is one of the most critical functions of the billing process. Therefore, your billing staff must be aware of these changes to get adequately paid for your rendered services.
Firstly, the 2023 E/M code changes, the American Medical Association (AMA) released the guidelines, including 225 new codes, 75 deletions, and 93 revisions.
Read more about these guidelines in our blog Get Ready for the CPT E/M Codes Changes in 2023.
On the other hand, the CY 2023 MPFS updates include changes regarding telehealth services and expanded coverage for colorectal cancer screening, behavioral health, and other covered services.
Read more about these updates on the blog What you need to know about the 2023 CMS Physician Fee Schedule
Medical billers are essential for your payment collection process. Billers calculate and collect payments for medical procedures and services. They are responsible for submitting, following up on, and appealing claims to insurance companies.
However, a lack of expertise in your medical billing staff can lead to increased denials and payment delays. Also, the billing staff often doesn’t have the time or expertise to audit and analyze the entire claim lifecycle.
Medical practices must conduct frequent billing training, so their staff is aware of updates and changes in the billing process. It is also essential to do audits at every specific time to make sure that the process is going as smoothly as it can be.
Certainly, outsourcing your medical billing can be a great option from a logistical and financial standpoint. Moreover, outsourcing this process can help you make more money faster, minimize overhead expenses, compliance and guideline adherence, and more.
Read more about the benefits of outsourcing your medical billing on our blog Five Benefits to Outsourcing Your Medical Billing in 2022
Automation in medical billing, data collection, medical coding, revenue tracking, and business monitoring can help you improve your KPIs and RCM. With medical billing technology, billers can quickly process accurate payments for physicians.
Technology can also help streamline workflows, save time, reduce manual errors, and identify mistakes that can affect the medical billing process.
Implementing medical billing technology can also help you reduce paperwork and minimize the risk of data loss.
Overall, taking advantage of technology in your billing process can lead to enhanced productivity, decreased denial rates, promoted accuracy, faster claim processing, and more.
At AdvantEdge, we understand the importance of the medical billing process for your practice.
AdvantEdge offers your group practice or hospital comprehensive medical billing services, including telemedicine billing services. Our entire company is focused on achieving superior results for clients, including ClientFirst service and fully transparent operations.
To learn more about navigating these challenges by outsourcing your medical billing, get in touch with an AdvantEdge expert or stay up to date on company and industry trends by visiting our Linkedin page.
A data breach is when an unauthorized party breaks into a company, individual, or organization’s system to disrupt, control, steal, or manipulate private, protected, or sensitive information.
Therefore, these breaches happen when someone is looking to exploit your software or personnel internally to gain access to private data. However, it can also occur unintentionally when someone from your staff or business associate accidentally sends or transfers information to the wrong party.
For medical practice purposes, a breach in particular is usually linked to data use or disclosure under the HIPAA Privacy Rule that compromises the security or privacy of protected health information (PHI).
According to HIPAA Journal, from July 2021 to June 2022, 692 significant healthcare data breaches were reported. Therefore, records of more than 42 million individuals have been exposed or impermissibly disclosed.
Among the leading causes of data breaches, ransomware attacks on healthcare organizations continue to be in high numbers. Other leading causes are:
In the first place, practices must have antimalware and antivirus software. Even if they are not 100% guaranteed solutions, they are essential to protect your practice from data breaches. According to the 2020 Ponemon Institute & IBM Cost of Data Breach Report, it takes an average of 280 days to identify a data breach. Current antivirus products contain features to detect unseen threats. These products can offer early detection of potential violations and provide an extra layer of protection.
This covers a wide range of topics, such as best practices for passwords and using multi-factor authentication whenever possible. It also includes encrypting hard drives in the office and reviewing employee access profiles. Audit internal and external staff to ensure they follow these basic security best practices.
Also, your practice should develop policies regarding control access, ePHI authentication, activity logs, audit controls, automatic logging off after a certain period, and message encryption and decryption.
Cybersecurity must become part of your organization’s DNA. First, you should adopt a security-minded culture. Then, schedule and conduct cybersecurity awareness training for all your employees. To follow up with your staff, conduct phishing tests to ensure they learned in training. Cybersecurity must come from the top, and employees should embrace it to be effective.
Medical practices’ IT, technology, and data security requirements differ from other types of businesses. It is critical to partner with an IT provider that profoundly understands HIPAA requirements and the business associate (BA) relationship. They should also be aware of the severe responsibilities entailed with overseeing devices and equipment that interact with and store PHI
At AdvantEdge, we understand the importance of having controls and safeguards in place to ensure the confidentiality, integrity, and availability of your PHI. Our team combines good policies and procedures with technology to protect your practice.
To learn more about best practices and how to protect your practice from data breaches, get in touch with an AdvantEdge expert or stay up to date on company and industry trends by visiting our Linkedin page.
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The Department of Health and Human Services (HHS) announced dates for the first year of the Medicare Drug Price Negotiation Program under the Inflation Reduction Act (IRA). This $739 billion package aims to lower drug costs for millions of Americans. According to the HHS statement, in 2023, the Biden-Harris Administration will begin negotiating to lower these prices for people with Medicare.
According to HHS Secretary Xavier Becerra, the department finally has the authority to get American families the lower prescription drug costs they deserve.
“Today, we are releasing our plan for implementing Medicare drug price negotiation under this landmark law. We will be transparent and aggressive in implementation every step of the way,” Becerra stated.
To clarify, this historic legislation allows Medicare to negotiate directly with drug manufacturers for prices of prescription drugs for the first time. The IRA authorizes Medicare to directly negotiate these prices for certain high-expenditure, single-source Medicare Part B or Part D drugs.
For a complete timeline of the Drug Price Negotiation Program implementation process, visit here.
According to Dr. Meena Seshamani, Deputy Administrator & Director of the Center for Medicare, public feedback is critical. This feedback will help them successfully implement this law. It will also allow them to ensure access to affordable and innovative treatments and therapies.
“Through this detailed timeline, we offer stakeholders the predictability they need to contribute to our implementation efforts. We want the public to know when and how they can make their voices heard on forthcoming policies,”, Seshamani added.
For decades, Americans have paid higher prices for prescription drugs than people in other countries. Also, HHS data shows that U.S. prescription drug prices are more than double (2.56 times as high) as in high-income countries.
For monthly updates, trends, and news, follow the AdvantEdge Linkedin page and visit our website.
The American Society of Nuclear Cardiology (ASNC) appointed Mouaz H. Al-Mallah as their new president. During his first President Message, Al-Mallah stated that nuclear cardiology remains the cornerstone of patient management.
According to the ASNC President, nuclear cardiology labs should consider upgrading to more recent systems. As a result, these labs should also use AI to enhance patient care and improve image quality at their centers.
“These enhancements to our diagnostic abilities will allow us to serve our patients better. This means we must use these new tools in our clinics and labs. Each of us has a responsibility to broaden our horizon and begin using the tools available to us now,” Al-Mallah explained.
Besides, the ASNC President added that nuclear cardiology imaging remains at the center stage in the era of multimodality testing. However, according to Al-Mallah, nuclear cardiology teams have plenty of opportunities to broader their horizons. Indeed, this is to ensure labs continue providing the best quality imaging.
Al-Mallah explained innovations that will impact nuclear cardiology and how cardiologists manage patients in the future.
In addition, among the innovations introduced in the past decade, the statement included cardiac PET, hybrid imaging, new tracers, amyloid imaging, new cameras, myocardial blood flow, new AI tools, and inflammation and infection imaging.
Al-Mallah also stated that the association would continue to support members and the wider cardiology community. This support will help ensure nuclear labs aim for and achieve the highest standards while introducing new applications to serve patients better.
Read the complete ASNC President statement here.
For monthly updates, trends, and news, follow the AdvantEdge Linkedin page and visit our website.
By Victoria Derlin, BS, BSN, RN.
As nurses, we hear the phrase ‘patient experience’ frequently. Nursing is a diverse career. We can work in all settings, from patients’ homes, offices, ambulances, helicopters, cruise ships, schools, and hospitals. We all come from different backgrounds, ethnic groups, and beliefs. Patients are always the priority and main focus wherever we work or our background.
Have you ever thought about what the patient experience means? Nurses are just one factor in the patient experience, but we have a tremendous impact. The patient experience starts as soon as a patient arrives or even communicates with the facility before coming. Consider a patient calling to make an appointment and is left on hold for over 10 minutes. Then the representative they speak with to make the appointment could be more friendly. The patient may interpret the office badly, even with that first phone call.
Every person impacts the patient experience they contact in the facility, from the cleaning staff to the administrators. For example, think about a patient or family member with whom you cross paths within the hallway. Do you say hello to them and smile, or do you rush past and not make eye contact?
Each of us needs to learn that we don’t know what people are going through. The person you just passed in the hallway may have just been told that they have cancer or maybe their family member is terminally ill. It does not take much effort to say a friendly hello to show that person a bit of kindness.
Many patients we come in contact with have chronic or painful medical conditions. Living with a medical condition can be exhausting and frustrating. They may not be able to have a job due to their situation, so it makes it difficult to pay their bills. They may not be able to have an everyday social life because they are in so much pain, or they just can’t do what their peers are doing. As a nurse, we must be able to understand and sympathize with our patients and their family members.
Nursing is difficult and stressful, and we are all flawed. Most likely, each of us has experienced being overworked and understaffed. We have had a patient or a family member treat us unkindly, aggressively, or threaten us when we try our best, even though many variables are out of our control. It is difficult to be treated like that and then go into the next patient’s room, be pleasant, and pretend nothing has happened. It isn’t easy to do, but we know we must go on. I am not saying it is fair, but it is the reality of a nursing career. We mustn’t allow our emotions to affect the experience of a patient or a family member.
Nurses learn so many life skills from nursing school and on the job. We know how to resolve conflict, handle stress, deal with different personalities, work with others, compromise, and speak up in difficult situations. Nurses often need to realize how resourceful and skilled we are.
Another essential skill I have learned as a nurse is customer service. You may think this is outrageous, but it is true: our patients are our customers. They usually don’t have to come to your specific company for care. They could go to the next hospital, doctor’s office, or health company. Patients have chosen to go to the company where you work. If they don’t have a good experience, they could go down the road to the next company. We can only nurse if we have patients. Good customer service skills are essential to a nurse’s role.
We sometimes need to find out what our patients and their family members are going through. Showing kindness is essential to being a nurse and a good human being. Next time you are having a difficult day, remember that we couldn’t be nurses without patients. We must be able to give them a good patient experience. Nurses will have complex patients who will not be happy no matter what we do, but if we put our best foot forward, we can confidently know that we tried our best and did our job. We might not have had a class titled “Customer Service” in nursing school, but it has always been an essential part of a nurse’s job.
Contact an AdvantEdge expert, or stay up to date on company and industry trends by visiting our Linkedin page.
The New Year means medical practices must be ready for new code and guideline changes regarding CPT Evaluation and Management (E/M).
The American Medical Association (AMA) released the guidelines regarding these medical codes effective January 1, 2023. Practices must be aware of them to prevent payment delays and run their businesses smoothly.
These changes include 225 new codes, 75 deletions, and 93 revisions. According to the AMA, “the CPT code set continues to grow and evolve with the rapid pace of innovation in medical science and health technology.”
In the Radiology section, there is only one new code (76883), which describes an ultrasound of the nerves and accompanying structures in one extremity.
Regarding Pathology and Laboratory, there are 11 new codes:
This section also includes three revised codes (81445, 81450, and 81455) to move the placement of some examples and descriptive wording within the descriptors.
Also, ten new codes have been added to the Medicine section. These include three codes (93569 and 93573-93575) as add-on codes describing injection procedures for angiographies during cardiac catheterizations and two codes (96202 and 96203) for multiple-family group behavior management/modification training for parents, guardians, or caregivers of patients with a mental or physical health diagnosis.
These new codes also include additional codes to describe the respiratory syncytial vaccine (90678), orthoptic training (92066), quantitative pupillometry (95919), and remote therapeutic monitoring for cognitive behavioral therapy (98978).
In Surgery, there are new codes in several subsections:
There are 46 new Category III codes representing various new and emerging services.
The addition or deletion of CPT codes requires the AMA to revise the descriptors of several other regulations in the E/M section, such as:
Revisions to other codes are for keeping with AMA’s guideline changes for E/M leveling using time or medical decision-making (MDM). Regarding these revisions, the emergency department codes 99281-99285, initial and subsequent nursing facility care codes 99304-99310, and home services codes 99341-99342, 99344-99350 are revised to require a medically appropriate history “and/or” exam and MDM, instead of all three key components.
Regarding Radiology, five codes (76882, 78803, and 78830-78832) have been revised to include clarifying words to the long descriptors. Also, Pathology contains revisions to codes 81445, 81450, and 81455.
The Medicine section includes seven revisions regarding the 92065, 92229, 92284, 93568, and 98975-98977 codes. Surgery includes modifications for codes 15851, 22857, 27280, 35883, 50080, 50081, 69716-69717, and 69726-69727.
Other revisions include home visit codes to include “residence” as a place of service, changes to the total time to meet when using time for code selection, minor clarifying word changes that have been made to the prolonged outpatient E/M service add-on code, and more.
Many observation codes were deleted due to the consolidation of inpatient and observation E/M codes in CY 2023. Other deleted codes include domiciliary or rest home and prolonged service codes.
Other deleted codes include:
For Surgery, the AMA deleted 18 codes that described the repair of various types of hernias. Category III includes 23 code deletions. Services represented by these codes may have either graduated to become Category I codes or were deemed obsolete. Laparoscopy codes 49652-49657 were also deleted.
Read the complete guideline changes here.
Learn how to keep up with these coding changes, increase revenue and optimize cash flow. At AdvantEdge, we understand that coding is one of the most critical functions of the billing process.
Counting on our AdvantEdge Coding Services can allow you access to coding audits, education, and compliance training. Our coding team will work as your own. We will ensure we develop a comprehensive coding workflow analysis and implementation adapted to your practice’s needs.
Contact an AdvantEdge expert, or stay up to date on company and industry trends by visiting our Linkedin page.
The cerebrospinal fluid (CSF) immune system shows key differences between individuals with cognitive impairment and those with normally functioning brains. This is the key finding of a Northwestern Medicine study published in Cell.
The investigators performed single/cell RNA sequencing on CSF from 45 cognitively normal subjects ranging from 54 to 82 years old. To che results proved an upregulation of lipid transport genes in monocytes with age. Basically, the study adds valuable information about how CSF immunity is altered with aging or neurodegenerative disease.
As a result, the researchers noted that older individuals experienced genetic changes that made CSF immune cells more activated and inflamed than their younger counterparts. Additionally, the study found that their CSF immune system becomes dysregulated as people age. In people with cognitive impairment, such as those with Alzheimer’s disease, the CSF immune system is drastically different from healthy individuals.
According to the study’s lead author, David Gate, Ph.D., the immune cells appear to be a little angry in older individuals. “We think this anger might make these cells less functional, resulting in dysregulation of the brain’s immune system.”
In the study, researchers of 14 participants with cognitive impairment—as determined by poor scores on memory tests—discovered the existence of inflamed T-cells with an overabundance of CXCR6 receptors cloning themselves and flowing into the CSF and the brain.
Even if the CSF is commonly known for brain protection against physical injuries, these findings also highlight the importance of the surrounding fluid of the brain to provide an immune defense.
“This immune reservoir could potentially be used to treat inflammation of the brain or be used as a diagnostic to determine the level of brain inflammation in individuals with dementia,” Gate said.
Read the complete study here Cerebrospinal fluid immune dysregulation during healthy brain aging and cognitive impairment: Cell.
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The American Hospital Association (AHA) commended the CMS for taking new and essential steps to increase oversight of Medicare Advantage plans. According to the association, these steps will help ensure enrollees have equal access to medically necessary healthcare services.
In the statement, Ashley Thompson, AHA Public Policy Analysis & Development Senior Vice President, explained that the AHA has previously raised concerns about the adverse effects of certain Medicare Advantage practices and policies.
All things considered, the statement explained that these policies have the potential to directly harm patients through unnecessary care delays or outright denial of covered services.
Therefore, the AHA commended CMS in the wake of new proposals. Generally, these proposals will tackle prior authorization barriers and excessive marketing practices, among other issues.
According to the CMS, this proposed rule includes policies that would improve beneficiary protections. They will also shore up guardrails that help CMS work to best meet the needs of beneficiaries.
In addition, “the proposed policies would increase access to care, including behavioral health services, and promote equity in coverage and care,” added the statement.
Besides the AHA commended CMS, the association also mentioned that they would continue carefully reviewing the proposed rule. They also stated their support efforts to improve the Medicare Advantage program for patients and their providers.
Read the full CMS proposed rule here.
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Clean claim submission is essential for your practice to get paid the money it has earned. However, this process might seem tedious and can consume a lot of resources and time from your staff.
Implementing some strategies in your practice to submit claims properly can help you reduce denials, accelerate the process of being paid, and ensure maximum return for your business.
Denial prevention is critical for increasing your clean claim rate. Also, taking a proactive approach can help you submit your claims properly and avoid payment issues.
Here is a four-point checklist to improve your claim submission process:
Claims must contain complete, accurate demographics and insurance details. They also need to comply with current federal and state regulations. Deficient and inaccurate data can be a struggle for medical practices.
According to a poll conducted by the Medical Group Management Association (MGMA), 36% of healthcare leaders reported missing information as the top reason for denials in their organization, followed by prior authorization (31%), eligibility (15%), out of network (5%) and other (13%).
Your front desk staff is vital in this task. Make sure there are proper processes to collect the data you need to bill for your services and improve your claim submission process.
Healthcare providers don’t have to know everything about billing guidelines. That’s where the billing and coding team comes in. However, understanding the basics can help providers enormously.
Some basic considerations you can implement are identifying if a code is primary and putting the diagnosis code attached to the code you are using. Make sure you add the reason for the patient’s visit. These aspects are essential to submit your claims correctly. Some providers put all the information they can in the claim. However, that is not going to help their claims get paid.
For some information, seek advice from professional billers and coders. They can help you improve the details of your claims. Billing professionals participate in continuing education to keep up with the latest billing and coding rules. Doing so ensures a clean claim submission process and can maximize reimbursements for services rendered.
Front office staff need to ask multiple questions to ensure they have verified the patient’s insurance and that it’s accurate and up to date. Other processes your front desk staff can consider when improving their verification process are:
Regarding authorization, you need to get prior approval for services that require it. Without authorization, the insurance payer is free to refuse the payment of a patient’s medical service as part of the health care insurance plan. For any service that requires authorization, if you do not obtain one, your claim will be denied and never paid.
Read more about why you should outsource your authorization process on our blog Why Should you Outsource your Authorization Process?
Identifying the reasons behind your denials and determining actions moving forward based on data analysis can be a vital strategy for your practice. A BI platform can provide you with drill-down capability to help you understand the reasons behind denied claims.
Based on that, you will know where your practice has issues and set action plans if needed to correct those.
Our AdvantEdge Analytics (A2) platform is a powerful web-based tool for medical billing reporting that provides complete transparency and allows you to monitor the entire revenue cycle of the practice, enabling faster and better decision-making.
Your practice will get complete visibility into the billing process and results. A2 makes medical billing reporting available “anytime, anywhere.” The dashboard shows the results of AdvantEdge medical billing services, including charges, adjustments, payment, A/R, encounters units, and more in summary form.rm.
At AdvantEdge, we understand the importance of submitting your claims correctly to reduce your denial rate, optimize your practice, and ensure that you get paid for your work.
Learn how to reduce your denial rate, increase revenue and optimize cash flow by outsourcing your claim submission process. Contact an AdvantEdge expert, or stay up to date on company and industry trends by visiting our Linkedin page.
The healthcare industry is evolving and should adopt technology tools to enhance processes and increase patient payments. The trends in healthcare payments show that there is more financial burden on patients due to higher deductibles, coinsurance amounts, and copayments.
According to the Statista Research Department, in 2020, the total U.S. out-of-pocket healthcare payments reached approximately 388.6 billion dollars. Health insurance out-of-pocket maximums have been increasing each year. The payment collection should evolve with the increased burden on patients to contribute to their medical bills.
Due to that, practices must be more proactive regarding technology in their patient payment collection process to keep their revenue flowing. This proactivity approach should include maximizing your technology efforts in the patient payment process to collect every dollar your practice has earned, maximize cash flow, optimize your workflows, and deliver outstanding patient experience.
Simplify patient payments by integrating these two processes. These can help track your collection efforts and make your payment process smoother. Also, make sure you deliver clear and concise patient statements to facilitate the payment process for patients.
Patients prefer digital statements, especially text over email, since it is easy to click and pay immediately. There are complications with staying with paper statements, such as wrong addresses and snail mail that patients do not read. It is also time-consuming and costly for your practice to send out, print and mail these statements.
According to the 2020 InstaMed Trends in Healthcare Payments Annual Report, 85% of consumers prefer an electronic payment method for medical bills. Also, make sure you have a patient payment portal in place. Patients want visibility into their payment process and to take ownership of their healthcare bills.
Going digital shortens the Revenue Cycle. Automating the claims status process is a massive win for your practice’s revenue cycle. Technology can help you with eligibility verifications, prior authorizations, missing information identification and analysis, and denials management.
Optimizing your backend processes can also help you speed up your revenue cycle process. These can give you more time to fix potential errors and optimize patient satisfaction.
Patient billing automation intelligently delivers text, email, and mailed statements to customers, saving valuable time, and getting you paid faster. This process can also help your practice simplify patient collections driving online payments, halting communication when payment is made, checking delivery status, tracking generated revenue, and more.
Learn how to incorporate technology into patient payment collections to increase revenue and optimize cash flow. Contact an AdvantEdge expert, or stay up to date on company and industry trends by visiting our Linkedin page.
On November 01, 2022, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that includes updates and policy changes for Medicare payments under the Physician Fee Schedule (PFS). This includes Medicare Part B issues, effective on or after January 1, 2023.
According to the CMS Final Rule fact sheet, the Calendar Year (CY) 2023 PFS final rule is one of several rules that reflect a broader Administration-wide strategy. The strategy aims to create a more equitable healthcare system that improves accessibility, quality, affordability, and innovation.
Physicians’ services paid under the PFS are furnished in various settings, including physician offices, hospitals, ambulatory surgical centers (ASCs), skilled nursing facilities, other post-acute care settings, and more.
CMS will increase the pay rate for iTind procedures in ASCs and hospital outpatient departments (HOPDs). The organization finalized an average pay rate of $7,274.78 in ASCs and $8,221.74 per procedure in HOPDs.
The 2023 PFS final rule expands Medicare coverage for specific colorectal cancer screening tests. This added up is achieved by reducing the minimum age payment and coverage limitation from 50 to 45.
CMS also expanded the regulatory definition of colorectal cancer screening tests to include colorectal cancer screening when a follow-up colonoscopy screening after a Medicare-covered noninvasive stool-based colorectal cancer screening test comes back positive.
CMS added four new procedures to the covered ASC procedures. The procedures are:
Medicare’s PFS final rule will reduce the physician pay conversion factor by 4.48 percent to $33.06. The conversion factor used to calculate physician reimbursement will decline by $1.55 in 2023.
CMS finalized the productivity-adjusted hospital market basket update to the ASC payment system rate. This update means an ASC payment system rate of 3.8 percent applied to ASCs meeting relevant quality reporting requirements.
Read the Calendar Year (CY) 2023 Physician Fee Schedule final rule fact sheet here.
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The American Society of Anesthesiologists (ASA) stated in a letter that the flawed implementation of the No Surprises Act (NSA) had created profound challenges for community anesthesiologists’ practices.
In the statement, the ASA urged the CMSs Center for Consumer Information and Insurance Oversight (CCIIO) to address an imbalance in the implementation of the Act. According to the Society, this imbalance has emboldened health insurance companies to push anesthesiology practices out-of-network and into a dysfunctional dispute resolution system.
The ASA described nine challenges faced by anesthesiologists and provided specific recommendations to address them. Among the most urgent are the following:
According to the letter, there have been ongoing reports of payers using inaccurate QPAs, many being unreasonably low and inconsistent with most local in-network contract rates. The ASA recommended the agency implement comprehensive audits of payer QPAs.
The ASA has received numerous reports of independent dispute resolution (IDR) holds on anesthesia claims. In these reports, some practices reported holds of hundreds of claims and holds in place for 90 days or longer with no explanation regarding the delay. The ASA recommended CMS lift these holds. The Society also suggested developing and implementing guidance that improves the IDR process.
In the statement, the ASA wrote that the CMS guidance continues a highly inefficient policy regarding batching anesthesia claims. The association said that this CMS policy limits the anesthesiologists to the same service facility, CPT code, and payer. The ASA recommended the CMS align its guidance with conventional anesthesia provider-payers contracting practices based on an anesthesia conversion factor.
Read the full ASA letter here: American Society of Anesthesiologists Proposes Nine Recommendations to Address Flawed Implementation of No Surprises Act.
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Workflow automation in healthcare supposes an opportunity for medical practices to improve care delivery. Automating some processes can positively impact providers, patients, administrative staff, and healthcare organizations.
Automation in healthcare can lead to multiple benefits for your practice, such as decreased manual efforts, reduced errors, increased capacity, and speeding up administrative processes. Automating your processes can also help you reduce staff burnout, improve interoperability, and effectively contain costs.
According to the 2021 Internet of Healthcare Report, 90% of healthcare executives say their organization relies on multiple systems for at least one process, including claims processing and clinical documentation.
Some processes, such as high volume, labor-intensive, rules-based, low variance, and well-structured workflows, can be automated. Automation consists of optimizing your processes to reduce the margin of error and handling massive amounts of paperwork so your staff can focus on more exciting labor instead of tedious and repetitive tasks.
Revenue Cycle Management (RCM) refers to the entire medical billing process, from beginning to end. RCM automation is essential to handle the complexity of tasks, ranging from patient eligibility to denials management. Automation can help you boost your performance and streamline your overall revenue cycle.
The more processes are automated or built into the system, the less the team must pivot, saving them significant time. At AdvantEdge, we optimize and automate each of our processes to deliver you the best RCM experience possible. Our unique approach enables healthcare organizations to succeed financially by efficiently assessing, planning, and improving their practice operations.
We manage your billing, coding, and claim submissions, so you can get back to what matters the most: your patients. Read more on the blog A Four-Point Checklist for Choosing your RCM Partner.
Scheduling appointments and patient reminders are essential to the success of your practice. If you invest in the right scheduling software, the platform can take care of the process so you and your staff can focus on more urgent matters. Choose software that synchronizes each patient’s appointment invitation with their email and calendar. This can help patients schedule and reschedule independently.
Also, automatizing this process will revolutionize your practice’s efficiency if you currently send patient appointment reminders manually. Read more scheduling tips for your practice on the blog 5 strategies to schedule your medical practice appointments effectively.
Not counting on automating processes in place for your Electronic Health Records (EHRs) can put your information at risk. Avoid incidents of filling incorrect data into the EHR system that can lead to misdiagnosis.
Automated workflows across your practice, including appointments, and medical test labs, among other things, can drastically reduce the margin of error. Automation software can back up your information safely on your cloud network. From there, providers can access the EHR data whenever they are and from their chosen device. Read more about how to select the right EHR for your practice on the blog 5 things you need to consider when changing your EHR.
In a practice workflow structure, approval is needed from an administrator or provider at every step. Automated workflows allow providers and administrators to give permission through their smartphone, tablet, or PC, no matter where they are. This automatic process can make the patient admission and discharge situation faster and hassle-free for the practice’s staff, patients, and their families.
The traditional onboarding process for providers can take a long time before they can join their duty. They must complete several formalities to start working at a medical facility. Organizations must collect the required information from the applicant and conduct primary source verification (PSV) of all the information provided.
The credentialing process is complex, time-consuming, and detail intensive. This tedious task takes a lot of work, follow-up, and tracking. Automating this process offers a high-tech solution that minimizes the errors and omissions often caused by antiquated manual credentialing processes. Read more about this on the blog 5 reasons to outsource your medical credentialing.
To learn more about how to automate your practice´s workflows to free up time & focus on your patients, get in touch with an AdvantEdge expert or stay up to date on company and industry trends by visiting our Linkedin page.
Prior authorization (PA) in medical billing consists of the process where providers determine the coverage of a rendered service, and the payer is authorized to pay for the service or treatment.
Without authorization, the insurance payer is free to refuse the payment of a patient’s medical service as part of the health care insurance plan. For any service that requires authorization, if you do not obtain one, your claim will be denied and never paid.
Your practice needs authorization for services that require it to keep costs in check, ensure medical necessity and reduce duplicated services.
According to the American Medical Association (AMA), prior authorization is overused and existing processes present significant administrative and clinical concerns. The 2021 AMA prior authorization (PA) physician survey stated that:
Prior authorization requirements can sometimes lead to delays or denials for care. These roadblocks cause frustration and worry for doctors, hospitals, and patients while adding to the mountain of paperwork doctors and hospitals must do.
The prior authorization process can take valuable time from providers that can use it to care for patients. Experts in this field can help you reduce burnout of your current staff and allow them to focus on higher priority tasks.
The future of PAs lands on automation. Fully electronic prior authorization is accelerating. Your current patient access workflow needs to be integrated with your authorization workflow to prevent delays in patient care and reduce denials.
A strategic partner will help you identify a potential opportunity for automation while relieving you of the administrative burden. For those authorizations that cannot be automated, it is essential to have experienced trained specialists to handle those exceptions.
The healthcare industry landscape is changing at an evolving pace. Finding a partner to help you solve your authorizations today is crucial. And can also prepare your practice for solving authorizations in the future.
To learn more about outsourcing your prior authorization process, get in touch with an AdvantEdge expert or stay up to date on company and industry trends by visiting our Linkedin page.
Organizations from the pathology landscape released a report offering recommendations for using in silico approaches for validating Next-Generation Sequencing (NGS) data analysis pipelines.
This manuscript is a joint report of the Association for Molecular Pathology (AMP), the Association for Pathology Informatics (API), and the College of American Pathologists (CAP).
In silico approaches for NGS data modeling has utility in the clinical laboratory as a tool for clinical assay validation. In silico data enables the simulation of a range of variants that may be difficult to obtain from a single physical sample. This data allows laboratories to test the performance of clinical bioinformatics pipelines more accurately without sequencing additional cases.
According to AMP Co-Chair of the In Silico Pipeline Validation Working Group, Justin Zook, the association convened a panel of subject matter experts of the three organizations to explore the advantages and disadvantages of these various types of in silico data. The report summarized vital findings and provided valuable recommendations to help clinical laboratory professionals select the most appropriate format for their specific purposes.
“As more laboratories around the country use in silico data to simulate variants to help validate the performance of clinical NGS data analysis pipelines, clinical laboratory professionals may need aid for understanding both the value these methods bring and the important nuances and limitations of these approaches,” Zook added.
The report reviews, analyzes, and presents the latest data to help guide clinical laboratory professionals on when and how to use these important supplementary in silico data approaches. AMP Co-Chair of the In Silico Pipeline Validation Working Group, Eric J. Duncavage, “we intend to review and update these consensus recommendations as new data and other in silico methods become available,” stated.
Read the complete report here: https://doi.org/10.1016/j.jmoldx.2022.09.007
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The Department of Health and Human Services (HHS) announced a new funding opportunity for states to develop and transform Certified Community Behavioral Health Clinics (CCBHCs) to address the country’s mental health crisis.
These funds from the Bipartisan Safer Communities Act through the Substance Abuse and Mental Health Services Administration (SAMHSA) will be a big push for CCBHCs to continue giving mental assistance. These centers are available 24 hours a day, every day of the week, and serve anyone needing mental health care or substance abuse, regardless of their ability to pay.
In 2021, the Biden-Harris administration also gave nearly $300M for new and existing CCBHCs. That same year, the Centers for Medicare & Medicaid Services (CMS) awarded this same amount in planning grants to 20 states to support and expand community-based mobile crisis intervention services for Medicaid beneficiaries.
HHS Secretary, Xavier Becerra, stated that “with these additional funds, we are delivering on President Bide’s commitment to strengthen mental and behavioral health for all Americans, including people living in our nation’s most vulnerable communities.” Becerra added that behavioral health is health and that there should be no distinction.
Ten states, Michigan, Missouri, Kentucky, Minnesota, Nevada, New Jersey, New York, Oklahoma, Oregon, and Pennsylvania, were selected from among 24 states that received one-year planning grants from HHS. States must obtain a planning grant to apply to the demonstration program.
The remaining 40 US states and the District of Columbia are eligible to submit applications for planning grants to develop CCBHCs in their states. In early 2023, up to 15 states will be awarded up to $1 million for one-year planning grants. From those that submit a successful demonstration application, ten will be selected to be in the actual CCBHC demonstration, starting in 2024.
This new funding opportunity adds to the recently released HHS roadmap for behavioral health integration. Read more about that in our blog HHS released a road map for behavioral health integration – AdvantEdge (ahsrcmprod.wpengine.com)
These efforts are one of the latest ones by the administration and Congress to address the surge in the need for mental health services. According to a recent poll conducted by CNN and the Kaiser Family Foundation, Americans believe the country is facing a mental health crisis. Read more about this in our article Survey Reveals Huge Gap in Coverage for Mental Health Services (ahsrcmprod.wpengine.com)
Review the complete HHS statement here: Biden-Harris Administration Announces Millions of Dollars in New Funds for States to Tackle Mental Health Crisis | HHS.gov
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Drive denials down to drive revenue up with these strategies you can implement in your practice.
Billing is one of the most critical processes in the success of every medical center. Most people involved in directing and operating medical practices understand that billing and coding require daily attention to detail, trained staff, and a solid tracking of ever-changing payer guidelines.
One main point in the billing process that needs special attention is denials. Some practices view denial management as the “catch-all” for unresolved claims. This attitude creates a negative perception and makes it uninviting for staff members to dig in and resolve open issues.
However, managing denials is not enough for practices to succeed. A comprehensive approach focusing on denials prevention and management can change your practice´s perspective and help you increase revenue.
The good news is that according to MGMA (Medical Group Management Association) data, 90% of denials are preventable.
Understand what the true denial reasons are. Deep dive into your denial reports and identify the main reasons your claims are denied. Be sure to track and analyze them at least monthly.
At AdvantEdge, we analyzed a sample of 30,000 claims and the resulting 1500 “first pass” denials and found that most of the denials were caused by a small number of reasons. These reasons include patients not insured or incorrect insurance information such as transposed digits, old insurance cards, etc.
According to an MGMA Stat poll, where the association asked healthcare leaders what the root cause of claims is denials/pends in their organization:
An MGMA article stated that most practices find that 80% of their denials result from 20% of the problems. Take the twenty percent of issues that cause eighty percent of the denials and identify the ones to be addressed with:
As with implementing any complex process, start eliminating one root cause at a time. Choose to focus first on one of them. Once you have selected it, make a plan to reduce those denials. Remember to set realistic goals for improvement.
This will enable staff members to gain insight into the process, recognize some substantial wins, and see the fruits of their work.
Accurate billing starts the first time a patient interacts with your practice. Improving the quality of information at the front end will result in significant benefits at the back end. Train your front-desk staff, especially schedulers and intake personnel.
Schedulers should know that obtaining or confirming insurance information is a crucial job responsibility for every call. A good practice is verifying the patient´s eligibility when scheduled, when they present, or both. This procedure also allows the practice to know the exact amount the patient is responsible for and collect some (or all) of it before the appointment.
Your staff should have the information needed complete to proceed with the appointment and make sure you collect every dollar you earn. Ensure you include referring physicians´ office staff and physicians on periodic training.
As your denial prevention process matures, pay particular attention to payer patterns. In today’s changing billing environment, you may experience jumps in denials from payers that had low rates just a few months ago. Analyze main denials that cause claims not paid in full – those should be considered partial denials.
Payer patterns and trends are beneficial for these cases since they equip the practice for discussing payments versus contracted rates with the payer.
To learn more about preventing denials and increasing your practice´s revenue, get in touch with an AdvantEdge expert or stay up to date on company and industry trends by visiting our Linkedin page.
