Before, during, and after the visit: 8 medical billing workflow best practices

Before the visit

Prior to the visit, the front desk will be responsible for verifying eligibility, obtaining the necessary authorizations, and collecting co-pays and co-insurance upfront.

1.  Be proactive in checking eligibility.

Denials are common, but preventable. If your front desk staff checks eligibility early, you can avoid denials and delays later in the revenue cycle. Checking eligibility helps determine the patient’s coverage status prior to the scheduled visit and gives you the information you need to be proactive about collections.

An important part of checking eligibility is collecting accurate demographic information to report on insurance claims. Be sure to keep a current and legible copy of the front and back of the patient’s insurance card on file for reference and check to see if there have been updates prior to the appointment. By doing so, you help prevent delays and denials and increase clean claim metrics.

To learn more about the clean claims ratio (CCR) and other key metrics, read this blog. 

At least two days prior to the visit, use your EHR’s electronic eligibility feature to capture any patient insurance information that may need to be updated. You can designate a team member to review the list daily, also checking for inactive plans and flagging those patients.

2.  Review patient responsibility, including deductibles, and look for referral requirements.

Make sure authorizations and referrals are approved, entered into the system, and linked to the corresponding visit. If they are not linked, a denial will result. In addition, you should always ask patients if their policy or coverage has changed — at every visit! Check for primary, secondary, and tertiary insurance, and ask about coordination of benefits (COB). Keep in mind that Medicaid is always the payer of last resort. Don’t submit Medicaid as primary.

During and after the visit

3. Ensure providers have templates set up for common procedures and diagnoses.

These templates should include modifiers and common diagnosis codes. Setting up these templates for providers will boost medical billing office productivity standards by helping staff post charges and reduce charge lag time.

4. Use charge rules/charge edits for common denials

To prevent denials and get paid faster, train providers and staff on coding errors. Use charge rules to avoid National Correct Coding Initiative (CCI) edits for bundling commonly used code sets. Look for covered diagnosis codes by procedure and common CPT codes that require pre-authorization.

Remember, the goal is to have the claim paid in full on the first pass. If a certain payer or CPT code always requires medical records, set up a rule to remind billers to send the records upon initial submission.

Send records electronically, when possible, to speed up the adjudication process.

5. Enter charges within two days of the visit date

By entering charges in a timely manner, you can avoid delayed revenue, as well as timely filing denials. Claims must follow several steps before they reach adjudication. They must be submitted, accepted at the clearinghouse level, accepted at the payer level, and entered into the adjudication process.

6. Use electronic claim submission

Consider the many benefits of electronic claim submission. It minimizes clearinghouse rejections, transmits to payers in real time, and reduces the cost of paper submission. In general, it speeds up the medical billing process, ensuring you get paid faster.

To learn more about the role of the clearinghouse in billing — including how the clearinghouse sends and receives electronic claim and financial information to insurance carriers — read this blog.

7. Check status reports

To reconcile claim batches, review clearinghouse status reports daily. If a claim is missing from the payer status report, it needs to be reviewed for missing/incorrect information and submitted again.

Reconciling claim batches daily is a very important — but frequently overlooked — component of the medical billing workflow.

8. Make your EHR the single source of truth

Any rejections corrected in the clearinghouse should be reflected in the EHR. This means you should update claims in the system with any changes made at the clearinghouse level. This strategy is important for A/R follow up and denial management. For tips on working medical claim denials, read this blog.

As the statistics show, practices face significant challenges in today’s climate. A dedicated financial partner can help your practice manage billing workflows and show you how to improve your medical billing processes.

When you partner with Greenway Revenue Services, you enlist a team that is committed to working with you to increase revenue and achieve financial health.