Medical billing plays a crucial role in the success of any healthcare practice, and cardiology is no exception. Cardiologists face unique challenges with medical billing due to the complex nature of their specialty.
According to IBIS World, cardiologists’ industry revenue has grown at a CAGR of 2.3% to $60.2 billion over the past five years, including an estimated 2.9% surge in 2023 alone.
The American College of Cardiologists (ACC) stated that by 2060, projected cardiovascular risk factors and disease rates will increase significantly in the United States. This rising cardiologist demand is mainly due to the growing burden of heart disease, which remains the leading cause of death in the United States.
This rapid growth must encourage cardiology practices to ensure a streamlined revenue cycle and maximize reimbursements. Therefore, understanding these main cardiology billing challenges and how to address them is essential.
- Challenge 1: Dealing with denied claims
- Challenge 2: Managing pre-authorization requirements
- Challenge 3: Keeping up with evolving coding guidelines
- Challenge 4: Ensuring HIPAA compliance
- Challenge 5: Balancing clinical and administrative work
Challenge 1: Dealing with denied claims
One of the most frustrating issues in cardiology billing is dealing with denied claims. Denied claims can lead to delayed revenue and administrative burdens. The denial rate indicates the health of your revenue cycle processes.
According to the MGMA (Medical Group Management Association), a 5% to 10% denial rate is the industry average but keeping the denial rate below 5% is desirable for your practice. A low denial rate indicates that your cash flow is healthy and fewer staff are needed to maintain that cash flow.
Approximately 90% of denials within any healthcare organization are preventable. However, medical practices struggle with keeping their denial rate low, which harms revenue collection.
To overcome this challenge
Thoroughly review claims before submission. Also, ensure accurate coding, proper documentation, and complete patient information. Remember to regularly monitor and address common reasons for denials, such as missing modifiers or incorrect coding, to minimize the likelihood of claim rejections.
Some other suggestions to address the most common denials are:
- Read back information to the patient / Ask them to review it in person at check-in
- Use online appointment scheduling
- Confirm eligibility prior to service
- Conduct a coding audit and training
- Leverage technology to automate processes
Read more about strategies to reduce your denial rate in our blog Simple steps to get your denials under control.
Challenge 2: Managing pre-authorization requirements
Prior authorizations (PAs) play a crucial role in cardiology billing, ensuring that cardiologists receive efficient and proper reimbursement for the services and treatments they provide.
The process involves obtaining approval from insurance companies before a specific procedure, treatment, or medication is administered. Cardiology procedures often require pre-authorization from insurance providers, and navigating the pre-authorization process can be time-consuming and complex.
According to a 2022 AMA prior authorization (PA) physician survey, physicians and their staff spend an average of almost two business days (13 hours) each week completing prior authorizations. Also, in this same survey, 88% of physicians describe the burden associated with PAs as high or extremely high.
To overcome this challenge
Develop a streamlined pre-authorization workflow. Training your staff to gather all necessary documentation, including medical records and clinical justifications, is essential before submitting pre-authorization requests. Having a dedicated team member responsible for pre-authorization can help ensure timely approvals.
It is also crucial that your cardiology practice:
- Understand insurance policies and guidelines
- Gather comprehensive patient information
- Maintain strong communication channels
- Leverage technology and automation
- Implement robust tracking and follow-up systems
Read more about this in our blog 5 Ways to streamline your prior authorization process.
Challenge 3: Keeping up with evolving coding guidelines
Coding guidelines for cardiology services are constantly changing and can be intricate. Staying updated is crucial for accurate billing and reimbursement. Cardiology encompasses many complex procedures and diagnostic tests, each with coding requirements and reimbursement rates.
Staying updated on coding changes is essential for cardiology practices. Being well-informed about these changes can ensure accurate and precise coding, facilitating proper reimbursement, reducing claim denials, and improving revenue cycles.
Additionally, cardiology practices benefit from staying current on coding changes, which helps them maintain compliance with regulatory requirements, avoid penalties, and enhance overall patient care.
To overcome this challenge
Invest in ongoing coding education for your billing team. Regularly review updated coding manuals and attend relevant training sessions or webinars. Consider partnering with a billing company specializing in cardiology to ensure your codes are up-to-date and compliant.
Also, remember to develop detailed procedure and diagnosis documentation templates. Clearly outline each procedure’s medical necessity and complexity to ensure accurate coding. Regularly update templates to reflect changes in coding guidelines.
Challenge 4: Ensuring HIPAA compliance
Maintaining patient privacy and adhering to HIPAA regulations is a priority in cardiology billing. Your cardiology practice must protect your information and implement reasonable safeguards to prevent violations and avoid sanctions.
Even with controls, violations and data breaches can still occur. While most breaches that occur are unintentional, they still represent a serious issue that can bring significant consequences. Failing to comply with HIPAA rules can lead to warnings, sanctions, and penalties affecting your business.
To overcome this challenge
Implement strict data security protocols and ensure your billing software and systems have robust security measures to protect patient information. Other actions you can implement in your practice to minimize HIPAA risks are:
- Take a proactive approach
- Educate your team periodically
- Have an incident response plan and backup data plan
- Implement technical safeguards
Learn more about HIPAA breaches and how to prevent them from happening in your practice in our blog 4 Steps to Reduce HIPAA Breaches within your medical practice.
Challenge 5: Balancing clinical and administrative work
Cardiologists often struggle between providing patient care and managing administrative tasks, including billing-related responsibilities. Cardiologists find themselves at the intersection of patient care and intricate billing procedures, requiring them to navigate both spheres efficiently.
On the one hand, they are entrusted with the critical task of diagnosing and treating complex cardiac conditions, demanding their unwavering attention and expertise. On the other hand, the administrative aspect necessitates meticulous documentation, coding, and claims submission to ensure proper reimbursement from insurance companies.
Relieving cardiologists from administrative burdens can allow them to focus on what matters most: patients. This is essential to improve patient outcomes while ensuring cardiologists get paid for their work.
To overcome this challenge
Delegate billing tasks to a dedicated billing team or consider outsourcing your billing to a specialized company. This allows cardiologists to focus more on patient care and reduces the risk of errors due to time constraints.
Some reasons why you should consider outsourcing your cardiology billing are:
- Get paid faster
- Reduce overhead expenses
- Increase patient focus
- Ensure compliance & guideline adherence
- Optimize financial transparency
Read more about this in our blog 5 Reasons to outsource your medical billing.
At Health Prime, we can help!
Health Prime understands that navigating the challenges of cardiology billing requires a combination of expertise, dedication, and continuous learning. Therefore, outsourcing RCM can be an excellent option for healthcare providers to reduce the administrative burden, save money and increase revenue.
We understand the complex cardiology billing and coding landscape. Our holistic approach tailors specifically to your practice’s needs. We manage your billing, coding, claim submissions, and more so you can get back to what matters the most: your patients.
Learn more about our PrimeRevenue services or 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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