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Challenges of Medical Billing and Coding

Medical billing and coding form the backbone of a healthcare facility or practice’s financial stability. Adhering to the most up-to-date billing and coding protocols can maximize reimbursements, maintain patient satisfaction and keep business operations humming.

Avila University’s online Master of Business Administration (MBA) with a concentration in Healthcare Administration program provides students with a fundamental understanding of the business side of healthcare. At the heart of these concepts lies medical billing and coding, which connect care delivery, accounting and insurance coverage. Specifically, the Healthcare Systems course prepares graduates to work within these interrelated fields by examining the revenue cycle’s impact on care delivery, utilization and managerial decision-making.

What Are the Fundamental Steps of Healthcare Billing and Coding?

Ideally, medical billing and coding work together seamlessly, and the process often starts as soon as the patient schedules an appointment or arrives for care. By following these steps, healthcare administrators can ensure they receive payments from payers and patients most efficiently:

  • Patient registration. Medical billers collect the patient’s demographic and insurance information, then verify insurance eligibility and coverage, including deductibles and copays. Billers can then inform patients of their financial responsibility and establish a payment plan if necessary.
  • Diagnostic and procedural coding. After a patient encounter, a medical biller reviews the physician’s notes to determine the correct diagnostic and procedure codes, including CPT, ICD-10-CM and HCPCS Level II. The codes must comply with HIPAA rules and guidelines specific to each payer.
  • Claim submission. After billers generate a superbill and validate codes, the claim is typically transmitted electronically to payers for reimbursement.
  • Claim adjudication. Payers evaluate the claim and determine if they will accept, reject or deny it.
  • Payers issue payment and medical billers calculate the remaining patient responsibility and subsequently issue a billing statement.
  • Follow-up and collections. If a patient or payer does not submit payment promptly, the medical biller may begin the follow-up or collections process to resolve the outstanding balance.

What Are the Most Common Medical Billing and Coding Issues?

Medical billing involves multiple people and systems and comes with its fair share of challenges. The following common billing and coding issues may result in a high rate of claim rejections or denials, delaying reimbursement and compromising an institution’s financial integrity:

  • Assigning incorrect or outdated codes
  • Collecting inaccurate or incomplete patient demographic data
  • Failing to help patients understand the scope of their insurance coverage and the resulting financial responsibility, especially for those with high-deductible health plans
  • Using manual claims generation and submission instead of automated processes with integrated checks and balances to verify accuracy

How Can Healthcare Staff Stay Current on Medical Coding and Billing Policies?

Codes and billing procedures frequently change, making it difficult for medical team members to stay updated. However, these tips can help staff remain knowledgeable of current trends:

  • Incorporate continuing education. AAPC offers continuing education on various billing and coding topics, with in-person and virtual webinars, conferences and workshops available. In addition, attending AAPC’s local chapter events offers the opportunity to discuss industry guidelines with colleagues and receive feedback on potential solutions for unpaid and denied claims.
  • Consider investing in computer-assisted coding technology. Technology can improve billing processes, boosting the accuracy and timeliness of claim filing and resolution by reducing human errors. In addition, coding software and algorithms can reduce monotonous tasks and allow medical billing and coding professionals more time to work on pressing issues, such as challenging claims and denials.
  • Monitor revenue cycle red flags. Implement a follow-up system that allows staff to report recurring red-flag issues, including an uptick in code denials, incomplete documentation or billing for undocumented services.

Overseeing a healthcare entity’s revenue cycle presents unique challenges for administrators, but following efficient billing and coding procedures can maintain financial security and regulatory compliance. Healthcare administrators can build these skills through continuing education like Avila University’s online MBA in Healthcare Administration program, which utilizes an engaging curriculum to equip graduates with the skills to manage modern healthcare organizations.

Learn more about Avila University’s online MBA in Healthcare Administration program.

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