Here's how it works: pre-bill technology analyzes all diagnoses, line-item charges, and E/M levels; applies hundreds of global and custom rules; and flags claims that have potential problems with revenue integrity. Then auditors focus on those specific claims. What’s potentially missing from the documentation? What payer rule was overlooked? What coding guideline was ignored? What must the organization do prior to claim submission to ensure accurate, prompt payment? “It’s about using staff more efficiently and effectively — not using more staff.”

For example, think about potential denials or recoupments your organization has faced related to E/M office visits, office-based procedures, chronic care management, or critical care management. A recent HHS report, for example, found that new patient level 4 office visits (99204) have an 11% improper payment rate. Established patient level 2 office visits (99212) have a 14% improper payment rate. The same HHS report found that chronic care management services (99490) are paid incorrectly nearly 65% of the time. Likewise, many healthcare organizations continue to struggle with denials for professional critical care management services when hospitals don’t bill for critical care on the facility side. These areas are all ripe for payer scrutiny, but when hospitals use pre-bill coding analysis technology, they can proactively safeguard against this and dramatically improve revenue integrity.

Responding to payer guideline changes with ease

Although hospitals aren’t immune from making mistakes, the reality is that payer policies also change frequently and sometimes for no apparent reason. An E/M level that was paid one day might not be paid the next. Pre-bill technology and revenue cycle automation can help healthcare organizations respond to these seemingly random changes with greater ease and without using more staffing resources. It’s about using staff more efficiently and effectively—not using more staff.

“Chronic care management services (99490) are paid incorrectly nearly 65% of the time.”

Leveraging new skillsets in revenue cycle management

Staff qualifications are an important consideration when adopting a pre-bill healthcare auditing strategy. For example, if a healthcare organization doesn’t have experienced pro-fee auditors to manage claims that the technology flags as potentially erroneous, managers may need to rethink job descriptions, qualifications, and retention strategies. The ability to audit complex cases will become paramount. So will the ability to educate physicians in real time as errors occur—not just once or twice a year when providers are audited. These educational opportunities will be targeted and specific, helping organizations develop and deploy resources more effectively.  

Looking ahead

Today’s healthcare organizations can no longer rely on small-scale professional fee audits that occur only once or twice a year. This approach simply doesn’t give healthcare leaders the insights they need to ensure revenue integrity. By analyzing 100% of professional fee services—and doing it prospectively before claims go out the door—organizations can safeguard the revenue they generate while simultaneously reducing administrative burden and increasing compliant revenue. To learn more about improving your revenue cycle management process, visit https://streamlinehealth.net/.