Cardiology Claim Processing: 4 Proven Strategies to Reduce Denials and Boost Revenue
Most cardiologists provide exceptional patient care. But they usually struggle with claim processing, which is a vital step for getting reimbursed for the service rendered. Anything going wrong at this step can lead to denials. Needless to say, too many denials can dent the entire revenue cycle. Therefore, streamlining this step is essential for ensuring the effectiveness of your RCM.
In this blog, we are going to discuss the ways you can strategize your cardiology claim processing for maximum output.
The Workflow Of Cardiology Claim Processing
Claim processing mainly involves verifying, submitting, and managing claims for medical services rendered. Understanding its steps and their nuances is vital to make it fruitful. Those steps include the following.
1. Claim Generation and Data Integrity
The claim submission process starts when you code the services and enter charges. This step is referred to as claim generation, and this is where data accuracy matters the most. You must ensure that you have entered all the details like patient demographics, insurance information, and practitioner’s details accurately.
2. Claim Scrubbing
Scrubbing in medical billing mainly refers to the use of technology that scans each claim for coding accuracy. It has become a standard procedure for fixing coding errors.
Common functions of scrubbers that support cardiology billing include the following:
- Modifier validation: The circumstances around cardiology treatments can differ significantly. This is why cardiology coding involves using modifiers more than many other specialties. What’s important here is that you only use potent scrubbing software. This software should conveniently validate complex cardiology coding modifiers like -25 (E/M services), -59 (unbundling), -52 (reduced services), and -26/TC (technical and professional components).
- Medical necessity validation by linking CPT and ICD-10 codes: A scrubber should not just check codes for errors; it should also link CPT procedural and ICD-10 diagnosis codes to validate medical necessity for the service rendered.
- Correct Coding Initiative (CCI) Edits: These edits help prevent improper unbundling of services. These are crucial in cardiology billing, as a majority of cardiology services get paired codes allocated. A scrubber equipped with these edits can help prevent bundling issues that can lead to denials.
3. Claim Submission Based On Payer-Specific Protocols
Adhering to payer-specific protocols is vital for preparing claims that bring full reimbursements. Since all payers have unique requirements for preparation, it is simply not possible to go with a one-size-fits-all compliance strategy. The best approach is to understand guidelines from each payer and formulate your strategy accordingly.
Some key steps to adhere to payer-specific protocols include the following:
- Delegating work to clearinghouses: Clearinghouses process claims on the providers’ behalf to secure reimbursements from the payers. A good clearinghouse like AltuMED will prepare your claims, perform scrubbing, and submit claims while ensuring accuracy and timeliness.
- Using portals provided by payers: In order to reduce the risk of denials with high-priority or complex claims, using payer portals may be a better choice. These portals perform functions like pre-submission eligibility verification and coding checks. This significantly reduces the risk of erroneous claim submission.
- Pre-submission verification: This step provides an extra layer of protection against claim errors. It involves checking whether your claim fits the criteria mentioned in the payer-specific guidelines.
Common Challenges In Cardiology Claim Processing
Cardiology practices face numerous challenges during claim processing. But three of them are more common than the others.
1. A Higher Rate Of Denials For High-Value Services
High-value cardiology procedures indeed bring in more revenue. But their higher rate of denials is a bothersome stat. Payers specifically pay attention to claims where services like stress tests, nuclear studies, echocardiograms, and interventional therapies like stent placement, angioplasty, and complex Electrophysiology (EP) studies are documented. Upon finding the slightest documentation anomaly, they deny or, at the very least, down-code the claim.
2. Modifier Misapplication
As mentioned above, modifier usage is pretty common in cardiology claim processing. Yet, it continues to be a confusing practice with a higher risk of misapplication. And this misapplication is the leading cause of denials in complex cardiology services. The top reason billing teams end up using the wrong modifiers is that a lot of nuances get missed during documentation.
3. Incomplete Documentation
Physicians tend to be highly proactive in patient care. But this very vigilance sometimes leads them to miss documenting many of their services. As a result, they cannot justify the bill for the services they have rendered. Sometimes, incomplete documentation even leads to details of medical necessity getting missed. As a result, insurance companies deny the claim outright.
Tips To Streamline Cardiology Claim Processing
Claims management can be tough, but not when you optimize it properly. Below are the ways you can streamline this process to ensure full reimbursements.
1. Invest In An Advanced Claim Scrubber
First and foremost, you must ensure that your claims are error-free. Their documentation, coding, and bundling should be flawless. For that, ensure that you are using an advanced scrubber. It should be a solution with a sophisticated algorithm that can examine all the nuances in the claims’ documentation and coding.
2. Set A Quality Standard For Claim Processing
It is imperative to develop and implement standard operating procedures (SOPs) for each step of claim management. Not only does this minimize errors, but it also prevents a hassle-like situation typically associated with an unorganized way of working. And the best part is that it provides you with enough room to train your staff for advanced operations.
3. Work on Proactive Denial Management
It is good to have a strategy in place to resolve denials as soon as they erupt. But it is better to prevent those denials from occurring in the first place. It just requires a shift in focus. You must have a zero-compromise policy towards completeness and accuracy of documentation, coding, and claim submission. One of the key ways to work towards this objective is to perform regular audits. This will help you spot patterns that lead to errors and denials.
4. Get Prior Authorizations Before Processing Your Cardiology Claims
Prior authorization can save you from a lot of trouble. It’s like an early assurance that you will get reimbursed after rendering the service. This is particularly helpful in high-cost cardiology services like stent placement, echocardiograms, nuclear stress tests, vascular angiograms, and many more. What’s important here is to have a robust system in place to send pre-authorization requests and track those requests until approval. This vigilant approach can also help you stay updated with payer regulations.
Important KPIs for Monitoring Your Claims’ Performance
Tracking is vital for ensuring the efficiency of your cardiology claim processing performance. The key metrics to keep an eye on in this regard include the following:
- Clean Claim Rate: Examine the percentage of claims that get through in the first pass. Ideally, you should aim for a clean claim rate of at least 95% to ensure a consistent stream of revenue.
- Claim Denial Rate: Stay current with the rate of claims that get denied. This simple metric will allow you to look further into the reasons for denials.
- A/R Days: Make sure that your A/R days for cardiology claims are no more than 30. A higher number than this typically represents an undermined follow-up strategy.
- Claim Processing Time: Looking at the time elapsed from claim submission to the final receipt can help you determine whether there are bottlenecks in your workflow. You can then re-strategize the process where things are getting slow.
Final Thoughts
Getting good at cardiology claim processing is not just about avoiding errors. It is a holistic aspect that requires a comprehensive strategy. This strategy emphasizes working on errors and accelerating work where required. It also stresses staying compliant with rules and regulations.
That said, claim processing can sometimes be too much of a task for cardiology practices that remain overwhelmed with patient dealing. The best approach for them is to outsource this vital work to a clearinghouse. At AltuMED, we offer cardiology practices comprehensive medical billing services, including claim processing. Our dedicated billing staff has both the expertise and experience to get you full reimbursements against your claims. For details, contact us today.
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