Reasons for Holdups in the Medical Billing Process


The revenue cycle process within healthcare is intricate and has led to disconnections among various stakeholders, including physicians, coding teams, billers, and administrators. This has resulted in the diversion of time and staff resources away from patient care towards revenue collection efforts. This situation leads to lost revenue, diluted patient care quality, and decreased staff morale due to frustration. A significant part of the issue is the segmented nature of the revenue cycle process, where the full consequences of each participant’s actions aren’t always visible or comprehended.

The exact locations and causes of these holdups are often unclear. In a recent survey posed to healthcare revenue cycle management (RCM) professionals, the question of the biggest holdup in the process was asked. Nearly 40 percent of respondents pointed to physicians either not generating or not finalizing their notes as the main source of delays. Another 25 percent indicated that coding posed the biggest bottleneck, with some mentioning problems involving billers, slow payments from payors, or staffing shortages.

Why were physicians often singled out as the primary holdup? Despite electronic medical records (EMRs) being common, many physicians still rely on outdated methods, such as paper, to track their daily patient lists for billing purposes. The efficiency of the physician determines whether these lists reach coders and billers.

Commonly, office administrators are tasked with collecting these paper records to compile a daily patient census for each physician, including visits to different locations throughout the day, all for the purpose of revenue cycle management. This process typically involves using spreadsheets. However, due to the constant distractions in a clinical setting, both physicians and administrators often set aside paper records, leading to the data being overlooked. This data never reaches the coder or biller, and the delay compounds as the next clinical day arrives. Although slow, this method of data capture is widespread.

While tracking the daily patient list is crucial, creating and signing notes for each patient encounter is even more critical. Physicians with tight schedules may intend to complete notes promptly, but they often fall behind in their schedule or want to review the notes for accuracy later. This leaves notes in limbo, impacting the medical billing process. Physicians are often unaware of the negative impact their actions have on the billing process, such as simple omissions like an attestation, which can halt the process. Until notes are finalized, coders are unable to proceed. After notes are completed, physicians may still slow the process if coders or billers need clarifications on content or codes.

Coders can also contribute to delays in the revenue cycle if they overlook or misinterpret key criteria within the notes, leading to undercoding (reducing owed amounts) or overcoding (exposing practices to audits).

Billers handle a significant volume of claims from various physicians and practices, both outpatient and inpatient. If certain pieces of information haven’t been properly addressed earlier in the process, these claims are often set aside for later attention. Unfortunately, as new claims come in, the prioritization of these set-aside claims tends to decrease, resulting in some being forgotten.

These delays and oversights on the front end directly impact billers’ ability to capture revenue on the back end. Each party involved tends to blame the other, leading to unnecessary administrative burdens and straining resources that could be better allocated to patient care.

Despite appearing minor to some participants, these issues can have a significant impact, often determining whether a health provider is profitable or not. For instance, if we consider an average claim worth $100 and assume that 10 claims go unnoticed each week for a single physician, the lost revenue accumulates quickly. This scenario applies regardless of the cause, whether it’s the patient list not reaching the biller, incomplete notes, missing or inaccurate demographic or insurance data, incomplete coding, lack of eligibility verification, or other details along the revenue process line. Depending on the practice’s size, this can result in tens of thousands of dollars lost per physician annually, and even more for larger practices and hospital settings.

Are there solutions available?

Innovations in digital health are addressing these disconnections by streamlining, monitoring, and tracking every step of the process. Some platforms incorporate artificial intelligence (AI) to help coders optimize code capture. These digital health platforms simplify the complex RCM process, offering transparency and accountability through concurrent audits. Some even incorporate cloud-based “zero trust” revenue cycle platforms for enhanced security. These platforms facilitate faster interaction among RCM team members, creating a successful model for the revenue cycle steps, from pre-registration to patient collections.

To address payment delays from insurance payors, the RCM team can establish a universal standard business contract for all providers. This contract could be based on factors like quality metrics, care complexity, and time spent on patients, including direct and indirect patient care times.

Digital platforms focused on this area provide transparency to points in the RCM process where claims are held up. By utilizing technology to minimize unnecessary follow-ups, the process becomes more efficient. This enhances the focus of each team member, enabling the redirection of resources toward patient care.