Reasons for Holdups in the Medical Billing Process


The revenue cycle function in healthcare is a complex process that has led to a disconnect between physicians, coding teams, billers, and administrators. The result is unnecessary time and staffing resources reallocated toward capturing revenue, instead of focusing on patient care. In the end, significant amounts of money are left on the table, patient care is diluted, and staff morale is lowered from frustration. Much of this has to do with the revenue cycle process playing out in silos. The full impact of lost revenue as a result of each player’s actions is not always apparent nor understood by the individual players in the process.

It is not always clear where or why the holdups are taking place. A recent survey, posed to healthcare revenue cycle management (RCM) professionals, “what is your biggest holdup in this process?” Almost 40 percent of respondents felt the biggest delays were attributable to physicians either not creating or not signing their notes. Another 25 percent of respondents suggested the biggest holdup was in the coding process, with some commenting that the problem lies with billers, slow payment by payors, or in staffing shortages.

Why were so many respondents pinpointing the physician as the primary holdup? While electronic medical records (EMRs) are commonplace for health records, physicians still stick to antiquated methods of tracking their daily patient lists on paper for billing purposes. Whether the list funnels over to coders and billers comes down to the efficiency of the physician.

Often, the office administrator is tasked to gather those pieces of paper and pull together a daily patient census for each physician in the practice, for each location visited within the day, for revenue cycle management purposes – simply using a spreadsheet. The information must then be delivered to coders or billers for next steps. But with constant distractions in a clinical workday, for both physicians and administrators, paper gets set aside, and isn’t scanned or faxed, and the data falls through the cracks. It never makes it to the coder or the biller. The turnaround time for resolution is extremely slow, compounding as the next clinical day arrives, making revenue difficult to fully capture with this method. But it is common.

Tracking the daily patient list is essential, but the responsibility of creating and signing notes for each patient encounter is critical. Physicians on a tight schedule may intend to create or finalize notes in a timely manner, but often fall behind in their schedule or have a desire to review the notes later for accuracy, leaving notes in limbo (or absent altogether). In many cases the physician is unaware of the negative impact they have on the billing process, and how simple omissions like an attestation can bring the process to a grinding halt. Until notes are finalized, the coders’ hands are tied. Once completed, the physician can still hold up the process if coders or billers require the physician to clarify content within those notes or regarding the codes.

Coders can also hold up or affect the revenue cycle when key criteria are overlooked or misinterpreted within the notes, leading either to undercoding (lessening the monies owed a practice) or overcoding (exposing the practice to Recovery Audit Contractor (RAC) and commercial payor audits.

Billers receive a mountain of claims each day, from multiple physicians and practices, outpatient and inpatient alike. When pieces of the puzzle haven’t already been put into place upstream on a particular claim, the claim is set aside in hopes of “getting to it later,” so effort can be focused on what is able to get out to insurance payors now. Unfortunately, the effort required to solve that set-aside claim often downgrades its priority. The claim gets forgotten as new claims come rolling in.

These delays and oversights on the front end affect a biller’s ability to capture revenue on the back end. And each party is pointing a finger at the other player. Simple oversights like these add to unnecessary administrative workload, stretching resources that could be better directed toward patient care.

What can appear to be a minor issue to a player in the chain can have an enormous impact, and is often the difference between a health provider being profitable or not. If you consider an average claim to be valued at $100, and assume that an average of 10 claims fall off the radar each week for just one physician, the lost revenue compounds quickly. This can be true regardless of the reason – whether the daily patient list never made it to the biller, the notes weren’t finalized, demographics or insurance was missing or featured incorrect data, coding was not complete, eligibility was not verified, or a myriad of other details up and down the revenue process line, halting the claim’s submission or creating a payor’s denial or rejection. Depending on the size of a practice, this can result in tens of thousands of dollars lost per physician, per year, and hundreds of thousands per practice, per year. The numbers grow exponentially higher in hospital settings.

Do we have solutions?

New innovations in digital health are solving these disconnects by streamlining, tracking, and monitoring each step of the process to nudge the individual players along, reducing frustration among the members within the revenue-cycle chain. Some platforms have incorporated artificial intelligence (AI), providing predictions to assist coders in optimizing code capture.

Advances in digital health platforms simplify the complex RCM business process to make it more transparent, with concurrent audits to hold indiviudals more accountable, and a few go as far as to incorporate cloud-based “zero trust” revenue cycle platforms for higher levels of security. RCM team members are able to interact faster and work together to create a successful administrative simplification model of the steps of the revenue cycle, including pre-registration, registration, charge capture, claim submission, remittance processing, insurance follow-up, and patient collections. To be able to create real-time dashboards allows practices to rapidly access insurance information, readily track (ideally, to a patient encounter level), streamline eligibility, manage the preauthorization process using decision-support systems, and engage in direct, real-time interactions between insurers and providers through secure portals.

For delays in payments made by insurance payors, the RCM team as a whole needs to create a universal standard business contract for all providers, based on quality metrics, complexity of care, and the time spent on patients, which ideally should include direct and indirect patient care times.

Digital platforms focused in this area bring transparency to the point in the RCM process where a claim is being held up. Technology has the ability to help reduce unnecessary follow-ups, making a more efficient and lean process. Everyone’s role becomes easier and more focused, and resources can be redirected to patient care.

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