Want to safeguard professional fee revenue? Consider a technology-driven pre-bill audit strategy

June 22, 2022 Streamline Health

By: Roberta Peters, MS, RHIA
Vice President, Solution Executive, eValuator™
Streamline Health

Twenty encounters per physician. That’s the number of visits many coding auditors review twice a year to determine whether providers are documenting and coding professional fee services correctly. When you think about it, it’s actually a very small sample size considering the volume of professional fee services most healthcare organizations provide. Do these audits really paint an accurate picture of what’s going on? Do they truly safeguard revenue? Likely not.

In addition, professional fee audits are usually done retrospectively, meaning long after the opportunity for corrective action. Even if a healthcare organization has a prospective professional fee auditing process in place, that process is usually very limited, targeting only a specific evaluation and management (E/M) level, a specific payer, or a specific provider. This means countless opportunities for corrective action are overlooked. Even healthcare organizations that use single path coding may prospectively audit facility and professional ED levels, but nothing else.



Rethinking strategies to protect professional fee revenue

These narrow approaches are often the best hospitals can do given today’s healthcare staffing shortages, the sheer volume of outpatient encounters, and the necessity for timely claim submission. Until now.

Pre-bill technology continues to transform hospital revenue cycle management as know it. More specifically, today’s healthcare organizations can analyze their professional fee services using a prospective, pre-bill strategy that leverages technology to enable a 100% review of professional fee claims. This approach equips hospitals with the data they need to identify and address problems in real time—all without increasing administrative burden or affecting discharged not final billed (DNFB) accounts.

Making the case for technology-driven, pre-bill healthcare auditing

To survive and thrive in today’s competitive healthcare environment, organizations must be one step ahead of payers. They must be able to identify patterns and trends that could jeopardize revenue integrity and then respond in real time with corrective action. One caveat? They can’t—and shouldn’t—use more human resources to do it. That’s where pre-bill technology can help.

Learn how automated pre-bill coding analysis can protect revenue integrity and improve financial performance.

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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/.

See for Yourself

As more providers are discovering, pre-bill technology is the key to optimizing revenue integrity and financial performance across all service lines. As the leader in solutions to optimize coding accuracy prior to billing, Streamline Health is helping providers establish a new normal that improves their bottom line despite these challenging times. To discover how we can improve coding accuracy and financial performance for your organization,
contact Streamline Health today.

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