Top Reasons for Revenue Loss in Physician Reimbursement and Their Solutions

Coding errors occur when you assign the wrong codes to patients’ diagnoses and procedures. Data entry errors or human biases remain the underlying causes for such mistakes. The most common types of coding errors include:

• Unbundling errors: Reducing a single comprehensive procedure into various smaller components and billing each separately.
• Upcoding errors: Billing patients for more complex and expensive procedures than what was actually performed or medically necessary.
• Outdated codes: Retaining outdated medical codes in billing systems and accidentally using them alongside updated ones.
• Undercoding: Reporting a lower-level or less expensive procedure than what was actually performed, either due to documentation errors, fear of audits, or lack of coding knowledge.
• Missing modifiers: Omitting necessary CPT or HCPCS modifiers that clarify specific circumstances of a procedure.

Although many providers still rely on highly manual processes for managing their bills, transitioning to RCM can deliver unprecedented tangible and intangible benefits. These include enhanced patient experience, fewer denials, increased revenue, decreased expenses, and cost efficiency.

In essence, RCM ensures you collect every cent you’ve earned through:

• Comprehensive data collection
• Insurance verification
• Data integrity
• Compliance adherence
• Patient communication and invoicing
• Claim submission and tracking
• Denial management
• Coding, customer service, and more

Here’s how.

RCM software is an extension of your financial intelligence. They simplify billing, minimize denials, and boost revenue with their vast technological capabilities, such as: 

Automated Engine

Regardless of how diligently we work, humans are prone to errors, and billing mistakes have long been a concern in the healthcare industry. RCM’s automated engine equips you with real-time eligibility verification, claim scrubbing, and auto-payment posting. While real-time eligibility verification ensures that only valid claims are processed by checking critical details such as a patient’s insurance status, coverage specifics, and co-payment requirements at the time of scheduling or check-ins, claim scrubbing guarantees that only accurate submissions reach the payers, controlling incorrect diagnoses or procedural codes from slipping through the cracks.

A/R Follow Up

Prolonged aging of claims is another critical aspect that healthcare providers struggle with. A sophisticated RCM software establishes an intelligent workflow that automates outstanding claim tracking. It issues reminders and alerts about approaching deadlines and prevents claims from going unpaid or becoming uncollectable. Moreover, its advanced predictive analytics flag high-risk cases and allocate them based on complexity, payer response times, and urgency, maximizing revenue while minimizing denials.

Coding Support

Coding errors arise from assigning incorrect diagnoses or procedure codes, missing modifiers, or using outdated coding sets. An AI-assisted RCM software automatically detects the most appropriate CPT, ICD-10, or HCPCS codes based on the clinical documentation. Moreover, built-in compliance checks ensure claims adhere to payer guidelines, regulatory standards, and Medicare/Medicaid billing requirements.

Customizable Dashboards

The most interesting part of the RCM’s customizable dashboards is that they provide all financial insights in one place and are easy to understand. They help providers identify significant KPIs, such as denial rates, payer performance, and revenue trends, empowering them to make data-driven decisions. Also, good RCM software is designed with role-based access so that different stakeholders can view and act on the data relevant to their responsibilities. 

Advanced Analytics

Advanced analytics is the key to addressing the growing complexities of healthcare reimbursement. With its sophisticated algorithms, including predictive modeling and machine learning, it examines historical claim data to uncover rejection causes and trends. This enables healthcare providers to develop targeted strategies for both self-pay patients and third-party payers, enabling the development of targeted payer-patient strategies. Additionally, its real-time revenue leakage detection helps identify and resolve uncoded procedures, unbilled services, and stalled claims within payer guidelines, ensuring better reimbursements and financial efficiency.

Claim Denial Management

RCM’s claim management feature excels in maximizing the first-pass claim rates. Powered by advanced denial tracking, categorization, appeal submission, and real-time error detection, it is widely recognized for recovering lost revenue and preventing unforeseen financial mishaps.