There are many complex regulations and steps involved when it comes to pathology billing and coding. Mistakes can occur at many points of your “front-end” and “back-end” processes. This can reduce collections and increase days in A/R, delay reimbursement, and lead to compliance violations or fines.
In today’s era of ongoing pressures on pathology reimbursement, finding and fixing mistakes in your billing process is more important than ever. Some of the most common errors pathology practices face are unbilled tests, eligibility errors, underpayments, and documentation gaps.
Here are some tips you can implement in your practice to prevent billing errors in your pathology practice and increase revenue
1. Unbilled pathology tests
The high volume of tests in a typical laboratory makes it easy for tests to go unbilled. The first control process that needs to be in place is accession reconciliation. Your billing system should identify missing accessions based on sequence numbers or a comparison with LIS or other lab reports.
Most billing systems interface with LIS, ADT, and other electronic systems, drastically reducing the error rate compared to paper. However, electronic interfaces require careful management of exceptions, such as rejected records.
If your practice’s charge information is on the LIS, ensure it matches the demographics from your ADT or EMR system. If not managed carefully, this matching process can cause tests to go unbilled. This, coupled with the high error rate in demographics, means there are always exceptions.
Managing these exceptions daily and assuring they are resolved is essential to prevent lost revenue.
2. Eligibility errors
Eligibility errors are one of the main reasons behind denials. The pathology group leadership and their billing experts (internal or outsourced) should meet with the administration to review and discuss eligibility denial results. Try improvements to the processes, such as online eligibility checks, verification of insurance information at discharge, etc.
Addressing the front-end process can more easily reduce eligibility errors for patients presenting for a lab test. Perform an online eligibility check at the time a test is ordered. Making the eligibility information readily available also allows for collecting the co-pay and, perhaps, the deductible before the test.
In some cases, the patient simply does not have coverage. Where possible, labs should identify and address these situations before performing the test. Also, don’t underestimate the need for patient education: patients may not be aware of the tests covered by their insurance, and many with high deductible plans chose them for the lower premium.
One of the primary sources of missed revenue is claim denials. Therefore, your team needs to work on each denial, ideally by automatically routing to the right specialist, then tracking to ensure it is worked on time.
More subtle, but often a source of substantial revenue, are underpayments of various types. This can happen when a payer remits the incorrect amount. Your lab must have a good handle on expected payment amounts. The only way to catch these errors is to have the expected amount programmed into your billing system or do a regular payment analysis.
Another crucial consideration is the fee schedule. If updates are necessary, you may submit claims below certain payer’s allowed amounts. Or you may have newer tests without a fee established. Plus, having the proper fee schedule is always helpful during payer negotiations.
4. Documentation errors
Correct coding is essential for insurers to accept claims and pay pathologists correctly and in a way that minimizes downstream denials.
Practices and departments should receive feedback from their internal coding team or outsourced partner on physicians’ error rates to highlight areas of improvement. Physician training is often very productive. Pathology practices’ leadership needs to stress the importance of accurate reports.
Due to the evolution of coding and payment mechanisms, documentation improvement processes are even more critical. Coders must have excellent detail for accurate coding and include the information in the first report.
At Health Prime, we understand the complex pathology billing and coding landscape. Our holistic approach tailors specifically to your specialty needs. We manage your billing, coding, eligibility & benefits, claim submissions, and more so you can get back to what matters the most: your patients.
If you want to learn more about how to improve your pathology billing, contact us at [email protected]. Our team will set up a meeting to discuss how Health Prime can maximize your revenue by cutting costs, saving time, and collecting more!
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