Addressing Billing and RCM Issues in Specialty Practices

Specialty practices face unique difficulties with billing and RCM. In this post, we highlight strategies for addressing these issues.

As more of the cost burden of healthcare shifts to patients, more patients and their families are paying close attention to the state of the economy and the impact it may have on the care they receive. This has led to patients doing their own research to arm themselves with insight into the potential cost of care before seeking and receiving care, especially specialty care. This is where RCM for specialty practices comes into play.

Over 60 percent of patients have made it known that knowing their out-of-pocket costs ahead of time greatly impacts their decision to pursue care. In addition, almost half of today's patients feel that having clear and concise information on expected out-of-pocket costs will help them determine whether or not to use a specialty provider. 

Adjustments to payer models have catapulted specialty providers to the front lines of efforts to control costs. However, there are some challenges to providing RCM due to disruptions in the healthcare chain. Specialty care presents unique complexities that set it apart from standard healthcare providers. Some fields require prior authorizations for a majority of their patients. Specialists consistently face challenges like claims denials that stem from failed pre-authorization or coding errors caused by the type of equipment used in patient visits. Also, insurance eligibility for specialty care is not always clearly defined, adding to the challenges of revenue cycle management (RCM) processes.

In specialty healthcare, RCM processes require more specialized tools and resources. With the constant changes in regulations, RCM in specialty practices requires careful attention to financial challenges that typically have a hyperbolic impact on a practice's financial stability. 

Common Billing and RCM Challenges in Specialty Practices

RCM for specialty practices - Medical team brainstorming during their training.

Healthcare providers frequently struggle with revenue cycle management and face a variety of obstacles. Let's explore the challenges specialty practices face with RCM.

Complex Coding and Documentation Requirements

Coding for specialty healthcare is an intricate part of revenue cycle management. However, complex coding systems and confusing documentation processes can impede a specialty practice's billing efforts. Keeping up with the ever-shifting landscape of healthcare is already a challenge within itself—from understanding how to accurately code for services to ensure that documentation meets payer specifications—it's no wonder so many practices struggle to keep up. With the constant updates to ICD-10 guidelines, coders must stay on top to avoid financial loss due to incorrect coding. 

Reimbursement Limitations

 “Reimbursement limitations” refers to the restrictions placed by insurance payers on the amount of money they are willing to reimburse specialty providers for specific procedures. These limitations create difficulties for specialty providers in covering the costs associated with delivering high-quality care. Specialty procedures may cost more due to their specialized nature. However, if the reimbursement rates set by payers are lower than these costs, providers may face financial challenges. Staying informed about coverage criteria and complying with payer rules is crucial, but demanding!

Authorization Prerequisites

When we think about the times when insurance eligibility is the most unpredictable, our mind typically goes to specialty services. Due to the unpredictable nature of insurance in specialty care, authorization prerequisites to care for each patient are crucial. Pre-authorization helps control costs, and it allows providers to provide evidence-based treatment to patients. The pre-authorization requirements vary among insurers, and determining the necessary steps for each patient's plan is not an easy task. Staff members already burdened with other practice-related responsibilities must dedicate considerable attention to managing authorization processes.

Multi-Procedure Invoicing

Properly handling invoices for multiple procedures involves navigating complex considerations. This includes determining which codes should be billed together or separately based on factors like the involvement of multiple physicians or adherence to bundling rules that payers have outlined. It's important that providers understand coding rules and insurance policies when dealing with multi-procedure invoices. For example, if two physicians are needed for a patient's appointment, those services should usually not be combined on the same invoice—but if only one physician provides all care, then certain codes may need to go together as part of bundling requirements. Not addressing these rules could lead to denied claims—ultimately hampering practice revenues and financial health over time.

Out-of-Network Claims Processing

Managing out-of-network claims presents its own set of challenges, often leading to higher denial rates compared to in-network claims. Denial rates for these types of treatments are often higher than in-network claims due to various factors like reimbursement rate discrepancies or stricter documentation requirements.

Navigating the appeals process is key if you want to increase your revenue capture from out-of-network services. Knowing how each insurer's appeal system works and what paperwork needs to be filled out and submitted is key. Plus, having a solid case ready that justifies the service rendered could mean all the difference between getting paid and not getting paid. Specialized expertise can help make dealing with out-of-network claims more manageable and profitable for specialty practices. Thus, making sure every penny owed is received, without sacrificing time or energy on denials and rejections.

Strategies for Addressing Billing and RCM Issues in Specialty Practices

RCM for specialty practices - Male doctor working on medical coding and billing using a computer.

Specialty practices can employ several strategies to tackle billing and revenue cycle management (RCM) challenges effectively. These strategies include:

Staff Training and Education

Train and educate billing staff on specialty-specific processes to ensure accuracy in coding and billing. Provide ongoing educational opportunities for employees to stay up to date on industry best practices, guidelines, and changes in coding regulations.

Specialty Coding and Documentation Requirements

Be aware of the specific guidelines surrounding different specialties when it comes to coding so that your specialty practice remains compliant with all rules and regulations—while avoiding costly claim denials due to documentation that was inadequate and/or billing codes that were not properly used during the process.

Technology and Automation Tools

Implement specialized software tailored specifically towards RCM solutions for specialty practices, as well as EHR systems with built-in features designed for ease of use when it comes to managing patient information through secure electronic means. This will help streamline workflows, reduce manual errors caused by data entry mistakes, and increase overall accuracy throughout the entire process from A to Z.

Streamlining Prior Authorization and Precertification Processes

Develop efficient methods of obtaining authorizations from insurance companies prior to starting any treatment. This can help minimize delays or rejections later down the line. Utilize automated authorization request technology such as apps or web tools where it makes sense. This way, you can easily track progress without having too many manual steps.

Regulatory Compliance and Specialty-Specific Regulations

The regulations that govern specialty practices can be complex and challenging. This makes it necessary for providers to have a good understanding of the rules they must follow in order to remain compliant with industry standards. It's also important for medical professionals to have an awareness of coding guidelines and reimbursement policies affecting their specialty practice. This helps them avoid any billing errors or fraud allegations which could land them in hot water with regulatory authorities.

For instance, “unknowing” HIPAA violations could lead to a penalty of a minimum of $100 per violation. It's important to closely follow these policies in order to avoid such costly consequences. To ensure successful compliance, specialists need effective strategies that will help them stay on top of these areas while avoiding costly mistakes along the way.

Final Thoughts

Female doctor reviewing a patient’s health insurance.

Specialty practices face a unique set of difficulties with billing and revenue cycle management (RCM). From complex coding to prior authorizations, it can be hard to stay on top of financials. To ensure you're capturing the most potential income, there are strategies you can leverage. BillFlash provides tailored services that could lighten your administrative load while optimizing RCM workflow. 

The key is understanding all the complexities involved in RCM for specialty practices. This includes multi-procedure billing, reimbursement limitations, and dealing with out-of-network claims. With these challenges come great opportunities to optimize revenue capture through smart solutions, like BillFlash RCM Services. Gain insight into what we offer and how it can help streamline processes within your practice, schedule a demo today!

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