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Pre-billing: A Safety Net - By Carlos Arias

May 06, 2017

Imagine driving on a narrow road between two mountains. Suddenly, rocks begin tumbling down around you from both sides. That is, I believe, the feeling many providers and healthcare companies get when a final decision from a federal or civil court gets published on the Office of Inspector General (OIG) website, knowing that more than 75% of compliance issues in healthcare are related to coding and billing practices.

A couple of years ago, after looking at our organization’s coding and billing process, we decided to put a process in place that we called a “pre-billing audit,” wherein we would audit coding and billing and document improvement opportunities. At the beginning, we encountered a lot of resistance from physicians who were claiming that they perceived a cash flow impact. They were right.

We learned that we did not have the needed human resources and processes to file the claims in a timely manner. It was painful. Our backlog could be as long as twelve weeks at a time, but we persevered. Top management was involved (the Board of Directors was engaged and guiding the process) -- we did not want to take any chances. Since then, our accuracy has increased to industry standard benchmarks and continuously improves.

Engagement of top management was our most important weapon. It helped us to identify our bottleneck: lack of human resources; training; and a system to monitor, evaluate and measure our coding and billing process. We also discovered that having an internal compliance coder team is very helpful, as is an IT database or software.

Our definition of the pre-billing process is the act of auditing the progress notes before a claim is produced. Think of it as “getting it right the first time.” You don’t want to have to re-code and re-bill the progress note--if you identify additional information after the bill goes out, it often raises a red flag from an auditing perspective.

For example, if a coder sees information that is missing in the record, then he or she should flag the case as containing a deficiency and delay final billing until an answer is obtained from the provider. The same goes for a scenario in which the coder feels that there is enough information in the record for a higher level of service. Ultimately, having a second layer of coding auditors from a Quality Assurance perspective is ideal.

Overcoding or undercoding are bad practices in the coding and billing world. Of course, you don’t want to hold these cases forever, since that impacts the revenue cycle. That’s another reason for the Medical Company to create a series of policies and procedures that:

  • Describe the process and workflow
  • Outline exactly how long to hold a case before final coding and billing
  • Define who is responsible for query follow-up
  • Describe exactly what to do (and what the next step is) if the provider doesn’t respond
  • Educate coders, billers, and providers
  • Provide feedback to providers and coders
  • Describe how it will monitor, evaluate and measure the accuracy of coders and billers

Facilitating the education of evaluation and management and ICD coding guidelines for coders and providers is the key to success in this process. Continuous internal and external audits to corroborate coding accuracy should be part of the compliance program. This system includes large investments in IT and Human resources, but I believe it is always worth it… It is, without doubt, a safety net.

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