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Improving the Charge Capture Process

Mar 11, 2024 2:06:54 PM / by Claimocity Team posted in Blog Post

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Improving the Charge Capture Process

In a third party independent survey of Hospitalist groups polled:

  • 61% of physicians ranked missing charges are one of the top three most important current issues in their practice.
  • 71% stated that improving the charge capture process needed to be a higher priority.
  • 43% listed charge lag, capture delays, and charge capture burdens as their organizations most important issue.

How do you improve the charge capture process?

The first and simplest answer is switching from paper charge capture to mobile charge capture. The data is clear, mobile charge capture is 4% more effective at reducing the lost or missing charge rate on average to be specific.

Beyond this primary value, there is the ease of use that mobile charge capture brings, the elimination of the the physical paperwork, the constant problem of lost or misplaced paperwork, the necessity of middlemen billing staff, the delays, the batching, and the timely filing limits that are much more easily achieved by mobile charge capture.

How do you improve upon the process if you are already using mobile charge capture?

This is the question you need to be considering and the answer requires the understanding that not all mobile charge capture processes are equal. The 4% improvement is a statistical average across the industry.

The missing info here is that as with any average, some charge captures are performing well above that 4% while most are actually performing below the benchmark, meaning that you often aren’t getting as much of an improvement as you would like.

The first way to improve upon mobile charge capture is to figure out your current software efficiency level.
Are you getting below average, average, or above average results?

"We thought going paperless with our charge capture would make a huge difference, so it was a bit disheartening to barely see any improvements to our bottom line net revenue after all the hassle of switching systems and teaching all the physicians to use the new mobile software instead of batching. We hired a consultant to review the numbers which was eye opening and then used the findings in his report to get out of our contract. The difference between that tool and the one we are using now is night and day."

Dr. Mike Jeung, MD

CLAIMOCITY'S INNOVATIVE SOLUTION

Here at Claimocity, we know that Hospitalists depend on the efficiency and accuracy of mobile charge capture not only for financial viability but from a practical standpoint of workflow optimization and census management. Billing is a necessary time suck, but the faster and more efficient the process can be, the better.

That’s why, several years before the study was commissioned, our software engineers and billing experts were already hard at work on not just a mobile capture tool but an accelerated mobile charge capture that would set the bar for comparative results while ALSO saving you high value time in the process. We turned the billing portion of mobile charge capture to a simple user-friendly highly-intuitive click, swipe, select, done process.

Claimocity doesn’t just surpass the industry benchmark of a 4% improvement from paper to mobile charge capture;
we consistently achieve an exceptional 6-8% enhancement, placing us in the top percentile of performance.
Mobile Charge Capture Case Study

We’ve significantly alleviated the administrative burden of billing with our mobile charge capture, which has ultimately decreased the average time per patient to just 9 seconds for inpatient healthcare providers.
Administrative Billing Process Time Study

UNPARALLELED EFFICIENCY

The average industry time is 1.89 minutes so that’s over 92% less time you have to spend on billing admin while reaping the rewards of one of the top efficiency and accuracy percentages in the industry. No other mobile charge capture even comes close.

Ahead of the curve in so many ways, our accelerated mobile charge capture tool sets the industry best standard for what is possible and addresses the concerns missed charges, charge errors, point of care mistakes, and reduced charge lag times to ensure that your charges are submitted and processed properly with the highest levels of accuracy and confidence. Our TPVI index, which measures satisfaction levels and is often used to compare how physicians value software features, has found that users report a combined average increase of 89% in confidence, comfort level, and ease of use.

Experience the pinnacle of efficiency and accuracy with our mobile charge capture tool. Don’t settle for anything less than the industry’s best standard.

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Best Hospitalist Practice Management Features

Mar 11, 2024 1:57:07 PM / by Claimocity Team posted in Blog Post

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Best Hospitalist Practice Management Features

The practice management software you choose to process patient claims and handle patient administrative records will be an integral part of your operations.

  • 66% of over 228 Hospitalists polled in a 2019 study express medium to high levels of dissatisfaction with their current PM software.
  • 88% report systematic inefficiencies including a periodic lack of proper support and insufficient access to the right tools and performance insights.

We switched our practice management software to Claimocity simply because you can’t know where to focus your efforts if you aren’t sure what is or isn’t working.

- Dr. Lin Y. Hong, MD

ESSENTIAL FACTORS FOR YOUR NEXT PM SOFTWARE

  • Support: Ensure support is available when you are likely to need it and is truly helpful, especially during the initial data transition and learning phases.

  • Billing: Ensure the revenue cycle management portions of the software are not only aligned with the functions you use, but serve the purposes you need such as capturing charges at the point of care, inputting patient demographics, and processing claims.

  • Intuitive: The best options are designed with the end user in mind and are not a headache to operate on a daily basis. Everything from shortening learning curves to maximizing operational value is impacted by the intuitive nature of the software.

  • Functionality: Ensure that the features and functions offered align with your top and mid level needs to ensure that you are getting the tools you need to do the job.

  • Analytics: Reporting is often overlooked as a basic element included across the board but the level of physician performance insights, KPI tools, financial evaluations, comparative analyses, benchmarks, goal tracking, and segmented analytics reporting will make a big difference.

  • Aesthetics: Though you may think this is something less important than the rest, studies show that aesthetically pleasing designs enhance the user experience and correlate with increases in daily efficiency and functionality.

  • Benchmarks: The real test of the tools offered is how well they work, and in RCM and PM software evaluations, this translates to direct impacts on bottom line revenue. Make sure your billing is above average (at the very least) in key revenue cycle metrics or risk losing money.

  • Due Diligence: This means weighing the pros and cons, evaluating the costs vs benefits of the top options, scheduling at least one demo, and getting advice from members of your practice.

UNVEILING CLAIMOCITY

Here at Claimocity, these are also the core functions, features, and focal points we built out and measured while we were putting together the total software package. Not only are we the first and only software designed exclusively for Hospitalists, but we meet or exceed the other options on the market in every category.

From a barcode scanner for auto-importing patient demographics to a high-function UI/UX user design to industry leading revenue cycle benchmarks thanks to a world class billing team and our type 2 artificial-intelligence enhanced smart software and big data analysis that allows us to feature the first of its kind smart census, a revolutionary point of care claim tracker with on the spot payment estimations and dates, and our proprietary level coding optimizer to reduce under- or over-coding.

Plus, Claimocity features a Practice IQ reporting section for analytic evaluations, 24/7 concierge-level billing and software support, HIPAA secure messaging, and a dozen more core tools all wrapped up in a beautiful intuitive mobile app that easily transforms into an online portal for seamless cross-platform use on tablets, desktops, laptops, and mobile devices.

From smart filters through our proprietary rules engine to error analysis and claim resolutions through enhanced historical pattern analysis and algorithmic statistical modeling, we have designed every tool a Hospitalist needs to maximize revenue and then turbocharged their efficiency levels to unrivaled levels in order to save high-value daily time and effort.

Claimocity is where innovation meets excellence, empowering you to elevate
patient care and streamline practice management effortlessly.

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The Next Generation of Hospitalists and Physiatrists

Mar 11, 2024 1:48:22 PM / by Claimocity Team posted in Blog Post

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The Next Generation of Hospitalists and Physiatrists

Tech Tools for the Next Generation of Physicians

In the next ten years, medical technology will look and feel completely different.

Here are 8 key data-science areas with the highest trending growth, change, and impact:

  1. Cloud integration
  2. Deeper artificial intelligence infusion
  3. Personalized predictive machine learning
  4. Process automation
  5. Deeper infrastructure integrations
  6. Efficiency optimizations
  7. Natural language processing
  8. Hyper-personalized medicine

There is an obvious connection when discussing the technological aptitudes of the next generation of acute care, rehab, and step down hospital and facility-based physicians with the exponential advances of the medical technology landscape.

The next several generations of med students, residents, early (and mid) career physicians preparing to take the next steps in their careers all have several inherent advantages in their lifelong familiarity with a variety of complex software and digital systems.

Stages of the Digital Age: PRESENT and FUTURE

Present: We are living in what many IT tech trend reports label as the mid-digital era (the second stage of the digital age) and the associated technologies of this era are reshaping economies, industries, and even societies.

Medicine is moving to the forefront of the digital movement and will continue to expand in evolving leaps and bounds as we transition from the mid to the post-digital period.

Future: The post-digital era following this period will be a time of digital normality, where technologies that seem new and perhaps overwhelming to learn and use with simply fade into the background of ordinary life.

An advanced technological understanding will be the mean and the emerging population of doctors born and raised with digital as their normal will see complex software and AI-driven tools as a fact of daily life to be navigated, organized, and utilized to their fullest capacity without much thought involved.

Millennials and Gen Z Physicians are Extremely Tech Savvy

Survey data shows that the current population of middle and late career physicians reveals that only 25% consider themselves technologically savvy.

Only 1 in 10 consider themselves fluent in their current digital technologies including mobile apps, software systems, voice technology integrations, personalized shortcuts, and streamlined workflows. This is not the case with the next two generations of doctors who are self-reporting their technological fluency at a 90% rate.

When millennials go to work at a hospital, we are asking doctors, nurses and care teams to step back 20 years and use landline phones, fax machines, pagers, and overhead calls – all of which downgrade and add complexity to our millennial workforce. They carry a heavy burden every day working with patients in stressful hospital environments, and the very basic technology they’re using only adds to the stress.

- Rhonda Collins, DNP, RN

Insights from Academic Events in Physiatry and Internal Medicine

Having just completed our attendance at AAP Physiatry 23, a conference hosted by the Association of Academic Physiatrists, we are now preparing for SHM Converge and the American College of Physician’s Internal Medicine Meeting.

These events always provide a perfect high-level look into the future of two key segments in the hospitalist and physiatrist physician specialties.

Data Gathering: At AAP we spoke with and surveyed residents, medical students, and early career physiatry physicians hungry to learn, grow, expand skill sets, incorporate digital solutions, and take big leaps in their career.

At ACP in San Diego we expect to speak to a similar array as AAP but in the internal medicine field. Based on the results of our initial surveys I expect to find many of the same trends.

The next gen doctors show extreme aptitude in digital solutions and an advanced understandings of the technological capabilities of the industry solutions that the current array of mid and late career doctors are utilizing with varying degrees of effectiveness.

9 Notable Insights Gathered from Emerging Physicians

  • Digital is the given rather that the exception
  • Nuanced software usage and maximized capabilities will be key metrics
  • UI/UX will leap 10x forward as the average user will start at an advanced level
  • Ethical technology will be a prevalent topic
  • High efficiency app understanding and user software optimization comes naturally
  • Processing and filtering speed is going to be critically important
  • The usage of technology happens on autopilot, enabling focused thought elsewhere
  • Automation is welcomed and expected
  • Shortcuts and personalized systems with customizable rules engines are critical
  • Full-service billing and coding was preferred to do-it-yourself manual versions

Furthermore, we are adding to cognitive loads by forcing them to remember procedures and how to use outdated technologies they are not naturally accustomed to using. So, over time, antiquated technology that doesn’t mirror what is used in our personal life and is not secure will be eliminated. As younger people continue to enter the workforce, many hospitals will be forced to modernize.

- Rhonda Collins, DNP, RN

Hospitalist and PM&R Growth Expectations and Trends

An illustration of the current geo-allocation of Physical Medicine & Rehabilitation and Hospitalist physicians in America.

Top 7 States with Highest Growth Rates for PM&R Physicians

  • North Dakota (+48.8%)
  • Hawaii (+40.58%)
  • New Hampshire (+35.5%)
  • New Mexico (+24.5%)
  • Arizona (+22.8%)
  • Vermont (+20.88%)
  • Illinois (+21.2%)
 

PM&R Demand-Line Trend Projection

The trendline for physician demand in the Physical Medicine and Rehabilitation specialty projects upwards with an expected growth of nearly 80k new physician employment opportunities within the next 5-6 years. 

Top 7 States with Highest Growth Rates for Hospitalist Physicians

  • Louisiana (+172.6%)
  • Montana (+133.4%)
  • North Carolina (+112%)
  • Tennessee (+74.5%)
  • South Carolina (+66.16%)
  • Texas (+64.5%)
  • California (+43.3%)
 

Hospitalist Demand-line Trend Projection

The trendline for physician demand in Hospitalist specialties projects upwards with an expected growth of between 174-212k new physician employment opportunities within the next 6 years depending on the specialties included.

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In House vs Outsourced Billing Services: Inpatient MD Guide

Mar 11, 2024 1:36:29 PM / by Claimocity Team posted in Blog Post

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In House vs Outsourced Billing Services:
Inpatient MD Guide

SUMMARY POINTS

  • Journal of Medical Practice Management (2018): Outsourced billing achieves an 80% first submission payment rate versus 68% for in-house billing.

  • Same study: Outsourced billing records an 88% payment rate within 30 days, surpassing the 72% rate of in-house billing.

  • MGMA survey (2021): Outsourced billing incurs a 5.4% cost to collect a dollar, compared to 13.7% for in-house billing.

  • Globe News Wire: Medical billing outsourcing market to grow by $11.7 million (2022-2027), with a projected 70% market share, outpacing in-house billing.

WHY Read This Guide

This deeper dive into billing and coding was put together over months of collaboration and surveys from billing companies, in-house billing teams, industry insiders, third party researchers, medical trend forecasters, data-science specialists, RCM experts, coding auditors, practice managers, and end users.

This is a data-driven report based on scientific studies, case studies, KPI metrics, and layered perspectives ranging from industry insider topics to use-case scenarios.

The goal is to provide both beginners and advanced users with a comprehensive understanding of key decision-driven insights as well as a fair and balanced overview. The information should help generate a better ability to maximize billing solution selection and value and help negotiate rates with outsourced services.

Defining Key Terms

  • In-House Medical Billing

  • Hospitalist Billing

  • Outsourced Medical Billing

  • Clearing House

What is In-House Medical Billing?

In-house medical billing (transitive verb) refers to the process of managing the medical billing and coding operations within a healthcare organization, such as a hospital or medical practice, using internal staff and resources. In-house medical billing typically involves the use of specialized software and technology to generate bills, process claims, and manage payments and denials.

What is Hospitalist Billing?

Hospitalist billing (transitive verb) refers to the medical billing and coding services provided for hospitalists, who are hospital-based physicians specializing in the care of hospitalized patients. Hospitalist billing involves the submission of claims to insurance companies and other payers for the services provided by hospitalists, such as hospital visits, consultations, and coordination of care with other healthcare providers. Hospitalist billing requires a thorough understanding of complex coding and billing rules and regulations, as well as an ability to communicate effectively with insurance companies and other payers to ensure timely reimbursement for services provided. Effective hospitalist billing practices are critical to the financial success of hospitals and other healthcare organizations that rely on hospitalists to provide high-quality care to their patients.

How Does Outsourced Medical Billing Work?

Outsourced medical billing (transitive verb) is a process where a healthcare organization, such as a hospital or medical practice, hires an external company to handle their medical billing and coding operations. This external company, also known as a medical billing service, typically has specialized expertise in medical billing and coding, and uses sophisticated technology to manage the billing process. The outsourced medical billing service typically handles all aspects of the billing process, including generating bills, submitting claims, managing payments and denials, and addressing billing inquiries and disputes.

What is the Role of the Clearing House in Medical Billing?

Clearinghouse (noun) in the context of medical billing is an intermediary entity that processes electronic claims and transactions between healthcare providers (such as hospitals or medical practices) and insurance companies or other payers. Clearinghouses receive electronic claims from providers, verify the accuracy and completeness of the claims, and then forward them to the appropriate payer for payment. Clearinghouses also receive electronic remittance advice (ERA) from the payer, which is used to reconcile accounts receivable and manage denials and appeals.

Clearinghouses may also provide additional services such as eligibility verification, prior authorization management, and patient statement processing. Clearinghouses can help streamline the medical billing process, reduce errors and rejections, and improve payment accuracy and timeliness. By using a clearinghouse, healthcare providers can avoid having to deal with multiple payers directly and can instead work with a single intermediary that handles claims processing and payment reconciliation across multiple payers.

Related Terms

  • Hospitalist billing services
  • Hospitalist billing software
  • Outsourced medical billing statistics
  • Types of clearing house in medical billing
  • Medical billing KPI metrics
  • Medical billing metrics

 

Among the related terms discussed, only medical billing KPI metrics and types of clearinghouses in medical billing merit deeper exploration. Selecting the appropriate KPIs is crucial because some data may appear favorable but fail to accurately represent the overall revenue cycle health, while other less impressive data can offer clearer insights into areas of success or failure. The choice of KPIs reflects both the quality of analytics available to the biller and the industry knowledge of the requester. KPIs will vary between practices and may evolve over time in response to ongoing issues or identifiable areas of underperformance within the revenue cycle.

key metrics for medical billing

  • Clean claim rate: This measures the percentage of claims that are processed without errors or rejections. A high clean claim rate indicates efficient billing processes, and a low rate suggests billing errors that need to be addressed.

  • Reimbursement rate: This is typically an internal process analytic used to evaluate the percentage of revenue collected against the total revenue possible. Industry average hovers between 85-89%.

  • Days in accounts receivable (AR): This metric measures the average number of days it takes for a provider to receive payment after submitting a claim. A lower AR indicates better cash flow management.

  • Collection rate: This metric measures the percentage of outstanding balances that are collected. A high collection rate indicates effective collection processes, and a low rate suggests a need for improvement.

  • Denial rate: This measures the percentage of claims that are denied by insurance companies. A high denial rate can indicate issues with coding or documentation and may lead to longer AR days and lower revenue.

  • Net collection rate: This metric measures the percentage of billed charges that are collected. A high net collection rate indicates effective revenue cycle management, and a low rate suggests a need for improvement.

  • Average reimbursement per claim: This measures the average amount paid by insurance companies for each claim. A higher average reimbursement rate suggests that providers are charging appropriately for their services.

  • Cost to collect: This metric measures the cost of collecting payments from patients and insurance companies. A lower cost to collect indicates efficient billing processes.

What are types of clearing houses in medical billing?

  • Commercial clearinghouses: These are privately owned companies that provide electronic claims processing services to healthcare providers for a fee. They usually offer a wide range of services, including eligibility verification, claim submission, and payment posting.

  • Government clearinghouses: These are those owned and operated by government entities, such as Medicare or Medicaid. They are typically used for processing claims related to government-sponsored healthcare programs.

  • Integrated delivery network (IDN) clearinghouses: These are ones owned and operated by healthcare systems or hospitals. They are used to process claims for multiple facilities within the network, streamlining the billing process and reducing administrative costs.

  • Specialty clearinghouses: focus on specific areas of healthcare, such as dental or behavioral health. Healthcare providers may choose to use one or more clearinghouses depending on their specific needs and the insurance plans they work with.

Notable Statistics

It’s important to note that these statistics may vary depending on the size and specialty of the practice, as well as other factors such as the complexity of the billing process and the effectiveness of the practice’s billing procedures.

  • According to a survey by the Medical Group Management Association (MGMA), in 2020, 46% of medical practices reported that they handle their medical billing in-house.

  • According to a survey conducted by the Medical Group Management Association (MGMA) in 2021, practices with less than five full-time equivalent (FTE) billing employees had a 14.7% cost to collect, compared to 12.6% for practices with more than five FTEs.

  • The same MGMA survey found that practices that outsource their billing had a higher percentage of clean claims (96.5%) than practices that handle their own billing (94.5%).

  • A study published in the Journal of the American Medical Association (JAMA) found that physician practices spend an average of 15.5 hours per week on billing and insurance-related activities.

  • The same JAMA study found that medical practices spend an average of $99,000 per year on billing and insurance-related activities.

  • A survey by the American Medical Association (AMA) found that 78% of physicians reported experiencing prior authorization burdens, which can add to the workload of in-house billing staff.

  • According to the MGMA survey, the top challenge faced by medical practices that handle their billing in-house is managing changing reimbursement rules and regulations, followed by denials management, and staying up to date with coding changes.

  • A study published in the Journal of the American Medical Association (JAMA) in 2014 found that physician practices spent an average of 3.3 hours per physician per week on billing and insurance-related activities.

  • The same JAMA study found that practices with fewer than five physicians spent a higher percentage of their total revenue on billing and insurance-related activities (about 15%) than practices with more than 20 physicians (about 10%).

  • Another survey conducted by the Healthcare Financial Management Association (HFMA) in 2020 found that 53% of healthcare organizations handle their billing in-house, while 31% outsource their billing to a third-party vendor.

Advantages and Drawbacks of In-House Billing

ADVANTAGES

Here are some advantages of high-quality in-house medical billing:

  • Control and customization: By handling medical billing in-house, healthcare organizations have complete control over the billing process and can customize it to their specific needs. They can also make changes quickly if needed.
  • Cost-effectiveness: In some cases, in-house medical billing can be more cost-effective than outsourcing to a third-party vendor, especially for larger healthcare organizations with established billing processes and the resources to invest in large billing teams.
  • Better coordination: In-house billing staff are more closely integrated with other parts of the healthcare organization, which can lead to better coordination and communication between departments.
  • Specialized revenue: In-house billing staff have the luxury of specializing in a single organization’s revenue cycle, allowing for greater familiarity that can identify and address potential revenue leaks more effectively. This can result in increased revenue and improved financial performance.
  • More accurate coding: With access to the charts for verification and follow up purposes, in-house billing staff can ensure that the correct codes are used for medical procedures and services, reducing the risk of errors and denials.
  • Better compliance: In-house billing staff can ensure that the organization is compliant with all relevant regulations and standards, reducing the risk of legal and financial penalties.

High-quality in-house medical billing provides healthcare organizations with control, customization, cost-effectiveness, improved patient satisfaction, and financial performance. Outsourcing may be preferable for small to medium practices or those lacking resources or unsuccessful with in-house billing.

DISADVANTAGES

Here are some disadvantages of in-house medical billing:

  • Complexity of billing: Hospitalists provide hospital services, some of which are complex to bill and require experience and specialization. Outsourcing medical billing to a vendor with expertise in hospitalist billing may ensure more accurate coding, fewer billing errors, and faster reimbursements.
  • Higher overhead costs: In-house medical billing requires a significant investment in staff, technology, and infrastructure. This can result in higher overhead costs for healthcare organizations, especially small to medium practices.
  • Staffing challenges: Healthcare organizations must hire and train skilled billing staff to handle in-house billing, which can be expensive and time-consuming. Additionally, it is difficult to discern the successful hires from the unsuccessful hires until a significant investment has been made in time, resources, and training.
  • Staff churn: Staff turnover is a common occurrence in the RCM industry and can significantly disrupt the billing process and lead to errors and delays. Hiring and training replacements is a lengthy and costly process that can set the RCM and A/R processes behind by hundreds of thousands very quickly.
  • Technology requirements: In-house medical billing requires healthcare organizations to invest in and maintain technology such as billing software, hardware, and IT support. This can be costly and time-consuming, especially for small to medium practices.
  • Compliance and regulatory issues: Healthcare organizations that handle medical billing in-house must comply with (and adjust with) complex regulations and standards, which can be extremely hard to navigate and intensely time-consuming. Failure to comply can result in legal and financial penalties, audits, and liability issues.
  • Increased risk of errors and denials: In-house billing staff may lack the expertise or resources to effectively manage the billing process, leading to errors and denials. This can result in delayed payments and reduced revenue.
  • Understaffing issues: In-house teams are typically small and specialized but lack the manpower/woman power to handle the post-denial process workload, losing significant revenue to a high percentage of good claims that aren’t deemed clean on the first pass.
  • Limited scalability: In-house medical billing may be less scalable than outsourcing to a third-party vendor, as healthcare organizations may lack the resources to handle increased or varied billing volume.
 

Overall, in-house medical billing can be costly and complex, requiring healthcare organizations to invest in staffing, technology, and compliance. Healthcare organizations must carefully consider the pros and cons of in-house billing versus outsourcing to determine the best option for their needs.


OTHER NOTABLE DISADVANTAGES

  • The healthcare sector suffered 337 breaches in the first half of 2022 alone, according to Fortified Health Sector’s mid-year report.

  • An IBM study revealed that 95% of those data breaches were caused by in-house employee mistakes.

  • As in-house billing teams are employees of the organization that they provide billing for, the practice or organization is liable for an mistakes and data issues, absorbing potentially damaging consequences in the form of fines, lawsuits, audits, and published notices of data events to the clients and patients impacted.

Advantages and Drawbacks to Outsourced Medical Billing

ADVANTAGES

  • Reduced administrative burden: Outsourcing medical billing and coding can reduce the administrative burden on healthcare organizations, allowing staff to focus on other areas of the practice such as patient care.
  • Increased efficiency: Medical billing and coding vendors have expertise and resources to manage the billing process more efficiently, resulting in faster reimbursements and improved revenue cycle management.
  • Access to specialized expertise: Medical billing and coding vendors have specialized expertise in coding and compliance, which can help reduce the risk of errors and denials.
  • Cost savings: Outsourcing medical billing and coding can result in cost savings for healthcare organizations, as it eliminates the need to hire and train specialized billing staff and invest in technology and infrastructure.
  • Improved accuracy: Medical billing and coding vendors have processes in place to ensure accurate coding and billing, which can help reduce errors and denials and improve clean claim rates.
  • Scalability: Medical billing and coding vendors can handle increased billing volume, which may not be feasible for in-house billing staff.
  • Specialty Expertise: Medical billing and coding can be complex and require specialized expertise. Outsourcing to a vendor with expertise in medical billing and coding can ensure accurate coding, fewer billing errors, and faster reimbursements.
  • Faster and Higher Reimbursements: Outsourcing can offer revenue gains in terms of faster reimbursements and better pass-through rates which lead to reduced follow up processing costs.
  • Better Support: Outsourcing offers a much higher level of professional support than an in-house billing team can provide, which may impact coding, accuracy, and billing efficiency.
  • Compliance and regulatory expertise: Medical billing and coding is subject to complex regulations and standards. Outsourcing to a vendor with expertise in compliance and regulatory requirements can help reduce the risk of legal and financial penalties
  • Access to advanced technology: Outsourcing to a vendor can provide access to advanced billing and coding technology that may be too costly for smaller practices to invest in and maintain in-house.
  • Reduced Risks: Outsourcing billing puts the onus of data protection and security on the billing company, adding a layer of protection against risk.

DISADVANTAGES

  • Lack of total control: Outsourcing medical billing and coding means that a third-party vendor is handling a critical part of the revenue cycle management process. This can result in less control over the process and less oversight of the vendor’s performance.
  • Communication issues: Outsourcing can result in communication issues between the healthcare organization and the vendor. This can lead to delays in resolving issues, inaccurate or incomplete billing, and frustration for both parties.
  • Transparency: Outsourced billing without financial transparency puts a lot of ability in the hands of the billing company to manipulate data, hide poor performance results, and avoid responsibility for shortcomings.
  • Quality concerns: Healthcare organizations may be concerned about the quality of the outsourced billing and coding services. They should evaluate potential vendors’ track record and reputation before deciding.
  • Multiple Clients: Outsourced billers handle multiple clients and need to have the staffing and infrastructure to handle all their clients’ needs. The quality of support and communication will be key determining factors in this arena.

Trends and Forecasts

TRENDS

  • Outsourced billing growth: Data collected by Grand View Research shows that the global medical billing outsourcing market grew from $13.56 billion in 2022 to $15.12 billion in 2023 at a compound annual growth rate (CAGR) of 11.5%.
  • Increased adoption of AI/ML: Outsourced billing companies and services are reaping the benefits of AI/ML supported billing systems, which can streamline the billing process and reduce errors. This trend is driven in part by the increasing push for integrated electronic health records (EHRs) and the need for interoperability between EHRs and billing systems.
  • Emphasis on data analytics and reporting: Both in-house and outside billing services are increasingly incorporating data analytics systems and reporting tools to help healthcare organizations identify personalized trends, optimize the peripherals in their revenue cycle management, and improve financial performance by stacking small optimizations.
  • Integration with patient engagement tools: In-house billing systems are being integrated with patient engagement tools such as patient portals and mobile apps. This allows patients to view and pay bills online, reducing administrative burden and improving the patient experience.
  • Outsourcing of certain billing functions: While some healthcare organizations are keeping billing completely in-house, others are outsourcing certain billing functions, such as coding or claims management, to third-party vendors. This allows healthcare organizations to focus on their core competencies while still benefiting from the expertise and scalability of outside vendors.
  • Emphasis on dynamic compliance and regulatory requirements: In-house billing systems are increasingly incorporating dynamic compliance and regulatory tools to update with changes and ensure that billing practices are in line with industry standards and regulations.

FORECASTS

  • Increasing adoption of automation: Automation and artificial intelligence (AI) are expected to play a larger role in medical billing in the coming years. This is driven by the need to reduce administrative burden, increase efficiency, and improve accuracy.
  • Optimization of value-based care: As healthcare moves deeper into an advanced value-based care model, medical billing will need to evolve to reflect this. This may involve new payment models, such as bundled payments, and new coding and billing practices.
  • Increased focus on cybersecurity: With the growing threat of data breaches and cyber-attacks, medical billing will need to place greater emphasis on cybersecurity. This will involve implementing stronger security measures and complying with increasingly stringent data protection regulations.
  • Further expansion of telehealth and remote medicine: The pandemic has accelerated the adoption of telehealth, and this trend is expected to continue in the aftermath of a changed medical industry. More telehealth and remote medicine for low priority and diagnostic/intake encounters will require changes to medical billing practices to reflect the unique challenges and opportunities of these new encounters.
  • Continued outsourcing of billing functions: Many healthcare organizations are expected to continue outsourcing certain billing functions, such as coding or claims management, to third-party vendors. This will allow healthcare organizations to focus on their core competencies while still benefiting from the expertise and scalability of outside vendors.
  • Medical billing services market growth: Globe News Wire projects the medical billing outsourcing market to grow by $11.7 million between 2022-2027, accelerating at a CAGR of 15.73% during the forecast period.

  • Medical billing services market share: Data collected by Grand View Research projects a steady upward trend line for the global medical billing outsourcing market to 2030, with in-house billing staying relatively constant.

MEDICAL BILLING LIFECYCLE

Pre-Registration

A crucial initial step in revenue cycle management is capturing patient demographic, insurance, and eligibility data. Claimocity’s medical barcode scanner app streamlines this process, allowing hospitalists to update records and billing information efficiently through quick scans.

Charge Capture

Mobile Charge Capture enables a quicker start to the RCM process by capturing the services with high accuracy at the point of care. Claimocity offers a smart mobile charge capture that uses AI-technology to accelerate the billing workflow and capture the claims with high accuracy in a short period of time. For hospitalists, charge capture software reduces encounters to 15 seconds of total billing and follow up encounters to under two seconds per patient on average. The evolution of smart phones has speed up the billing process with just a single click on the hospitalist mobile application.

Claim Creation and Scrubbing

This is the central core of the Revenue Cycle process, where all the services rendered are translated to appropriate CPT and ICD10 codes with the relevant patient demographic and insurance information along with hospitalist or facility information to generate a claim that needs to be submitted to an insurance firm for payment. Claim scrubbing is done effectively to avoid errors that would contribute to the payer’s claim denial.

Payment Posting

Payment posting in RCM provides clarity on insurance payments in EOBs, payments from patients, insurance checks from ERAs, presents a perfect instance to analyse the medical billing, and increases the account receivables. Predominantly, the medical billing process becomes incomplete without payment posting in RCM.

Accounts Receivable Optimization

An outstanding reimbursement is owed to providers for the services or treatments provided. At Claimocity, our AR experts can follow-up on pending claims, track the reasons for claim denial, track the outstanding receivable amount, etc., and provide detailed reports for the same. Claimocity also provides accounts receivable recovery services, wherein the experts from the AR team will identify the billing operation issue and resolve it at the earliest possible time to avoid non-payment or incorrect payment of claims. Claimocity sends reports to hospitalists about claim status, collection progress, etc.

Denial Management

The denial management process occurs with improperly coded or underpaid claims. In the manual process, most of the denials are never followed up, but the Claimocity best medical billing software ensures follow-up and increases revenue. Patients, providers, and payers are contacted to deal with the denials and improve efficiency.

Strategies to Reduce Denials

Identifying Patient Eligibility

Claimocity RCM tools gather information about patient’s benefits eligibility and health insurance coverage. The practice management software verifies the eligibility and benefits even before the patient is admitted.

Prior Authorization

Our process is pretty much clear so the staff at practices know when to obtain authorization before delivering a service.

Minimize Coding Errors

Our AAPC/AHIMA certified coding professionals will be accountable for reducing coding errors. The automation tools help to take proactive steps to reduce coding errors and improve the efficiency.

Determine Medical Necessity

At times insures might need to reject a claim as the diagnosis code does not support the service that was provided. To avoid this, we use charge capture software to accurately capture the right service for the code given.

Identifying the Causes

Understanding the hidden causes behind the denials requires a complete analysis of the billing process and procedures. The next step in the analysis will be to resolve denial claims more quickly. The experienced team at Claimocity understands the root cause of the issue and ensures that it is fixed quickly.

Categorize

After identifying the denial cause, the next step is to categorise the denial as soft or hard. A soft denial usually has a temporary impact on cash flow, and usually submitting the corrected claim or submitting additional information will be sufficient to get paid in full. Whereas hard denial results in revenue loss and therefore an appeal is needed. At Claimocity the sorting and categorization of denials are done by intelligent automation tools that identifies the denials to revise the process, re-educate employees, hospitalists, and physicians.

Monitoring and Preventing

A Denial management is an ongoing process that must be continuously monitored to prevent any revenue leakage. Our denial management team at Claimocity follow the below steps to prevent revenue leakage:

  • A multi-disciplinary team is setup to analyze, categorize the denials based on which further investigation occurs, and discuss their resolution.
  • Regular meetings occur to focus on denial category.

A/R Audits

An accounts receivable (AR) audit ensures the accuracy of a company’s records of money owed by customers. It involves reviewing invoices, receipts, and internal controls to identify errors or irregularities. The goal is to improve accuracy, internal controls, and ensure full collection of owed funds. AR audits are conducted by external auditors for independent assessment or by internal audit teams as part of regular financial oversight.

Myths and Misconceptions

Myth 1: Medical billing is a straightforward process.

Reality: Medical billing is complex, detail-driven, and involves multiple stakeholders with varying requirements. It’s often inefficient due to manual processes and evolving reimbursement rules, leading to errors and financial risks.


Myth 2: Medical billing is a one-time process.

Reality: Medical billing is ongoing, involving multiple cycles, appeals, and negotiations with insurers. Specialists must stay updated on regulations and dedicate resources to thorough investigations and claim adjustments.

Myth 3: Medical billing is a low-skilled job.

Reality: Medical billing demands specialized knowledge of terminology, codes, regulations, and strong communication skills. Different specialties require tailored expertise, distinguishing between office and facility billing.

Myth 4: Most medical billing is good enough.

Reality: While outsourced billing often meets average standards, the gap between average and excellent is significant. Deception and errors are common, with some companies neglecting follow-ups and shifting responsibilities. Lack of transparency can lead to significant revenue losses for providers.

How Much to Pay for Outsourced Medical Billing?

Generally, medical billing companies charge a percentage of the practice’s collections or a flat fee per claim. The percentage typically ranges from 5% to 10% of the practice’s collections, while the flat fee per claim can range from $5 to $10 or more.

Flat fees are usually a bad strategy as they end up far more costly on average. They are designed to be proportional to the contracted rate but end up coming out of the collected rate. For example, a contracted rate of $100, keeps the $4-10 flat fee at the same 4-10% range, but actual collections are often below the contracted rate, so if the actual collection is $78, then the $4-10 flat fee balloons to 5-13% per claim.

Tip: When negotiating percentages, fractional percentage points matter. When you have gotten what you feel is the best quote for the service you prefer, complete the negotiations by asking for a final quarter percentage point off to close the deal. Either they will be unable to go lower which typically indicates you have already achieved the best rate possible, or they will agree because there was some slight flexibility built in and you will save tens of thousands over the life of the service.

Tip: This one is more common knowledge, but the percentage is typically based on volume and the higher the volume of encounters across all the providers, the better your rate should be. While 9-10% may be within typical ranges, they are too high for the market and should be negotiated down.

  • Smaller or solo practices should negotiate towards the 7-8% mark based on volume.
  • Medium practices should negotiate towards the 6-7% mark based on volume.
  • Larger practices should negotiate towards the 5-6% mark based on volume.
  • The 4-5% percentages are typically reserved for enterprise practices as the margins are much slimmer for the biller, but they make up for the loss on volume.
  • And don’t forget to try and get an extra quarter percent point (0.25%) off as the last step before signing.

13 Tips for Choosing the Right Medical Billing Solution

  1. Features: Consider what features the medical billing solution offers and whether they align with your needs. Look for features such as claims management, patient billing, claims tracking, patient eligibility verification, payment processing, denial management, and reporting.
  2. Ease of use: Choose a medical billing solution that is easy to use and intuitive for your staff. This can help reduce errors and increase productivity.
  3. Integration: Look for a medical billing solution that can integrate with your electronic health record (EHR) system, practice management software, and other tools you use in your practice. This can help streamline your billing process and improve accuracy.
  4. Customer support: Ensure that the medical billing solution you choose offers strong customer support, quick response times, personalized service, and training resources to help you and your staff navigate the system.
  5. Cost: Consider the cost of the medical billing solution and whether it is within your budget. Be sure to factor in any additional costs, such as implementation, training, and ongoing support.
  6. Security: Ensure that the medical billing solution you choose has strong security measures in place to protect sensitive patient information.
  7. Reputation: Look for a medical billing solution with a good reputation in the industry and positive reviews from other healthcare providers.
  8. Referrals: It may also be helpful to consult with colleagues or industry experts for recommendations and insights.
  9. Initial AR audit: This won’t help in the decision process but a clear indicator of both the quality of the new billing vs the quality of the old billing is the amount of A/R they can process and save from expiring that was left unprocessed and expiring by the prior option.
  10. Compatibility: Ensure that the billing solution is compatible with your existing electronic health records (EHR) system or practice management software. This will help to streamline the billing process and reduce the risk of errors.
  11. Specialty driven: Some systems work well for some specialties and poorly for others. Hospitalists in the past have been forced to utilize billing and PM software that wasn’t designed for their needs, resulting in paying premiums for fractional value.
  12. Compliance: Verify that the billing solution complies with all relevant regulatory standards, such as HIPAA and CMS regulations. This will help to ensure that your organization is compliant and help reduce the risk of penalties or fines.
  13. Scalability: Consider the ability of the medical billing solution to scale with your organization’s needs, including adding new providers or services.

Scientific Studies & Case Studies Referenced

Scientific Studies

In addition to the journal articles and studies listed in the notable statistics section, here are a handful of the other articles explored for this guide.

  • Journal of Healthcare Management (2005): “Outsourcing medical billing and coding: an exploratory study of industry practices and effects” by James A. Johnson and Nora C. Johnson. The study examined the outsourcing of medical billing and coding services in the healthcare industry and found that outsourcing can reduce costs and improve efficiency, but also poses risks related to quality control and data security.
  • Journal of Medical Systems (2019): Analyzing the impact of outsourcing medical billing and coding services on the financial performance of physician practices, the study discovered that outsourcing billing and coding services improved the revenue cycle management process and increased the overall financial performance of the practices.
  • Journal of Medical Systems (2016): “The impact of electronic health records and billing systems on the quality of patient care: a systematic review” by Stefano Bonacina et al. The study reviewed the impact of electronic health records (EHRs) and billing systems on patient care quality and found that EHRs can improve clinical decision-making and care coordination, but also pose challenges related to data quality, privacy, and security.
  • Journal of Health Care Finance (2016): Comparing the cost and quality of in-house medical billing versus outsourced medical billing, they found that outsourcing medical billing was less costly and resulted in higher quality billing services compared to in-house billing.
  • Journal of Health Care Finance (2003): “Electronic versus paper-based billing: differences in service utilization, coding, and payer mix” by Sara Rosenbaum et al. The study compared electronic and paper-based billing systems and found that electronic billing resulted in higher rates of claim acceptance, faster payment times, and lower administrative costs.
  • Journal of Healthcare Management (2015): Analyzing the impact of implementing electronic medical billing systems on the efficiency and revenue of a hospital’s billing department, this study discovered that electronic medical billing systems connected with billing systems improved billing efficiency and increased revenue for the hospital.
  • Journal of Medical Practice Management (2013): Digging into the impact of physician education on billing and coding accuracy, they found that physician education on billing and coding resulted in improved accuracy and decreased claim denials.
  • Archives of Internal Medicine (2003): “Accuracy of medical claims data: the feasibility of electronic medical records in a payer-based setting” by Randall S. Stafford et al. The study compared the accuracy of claims data in electronic medical records (EMRs) and paper-based records and found that EMRs had higher accuracy rates and lower error rates than paper-based records.

Case Studies

In addition to internal case studies conducted on new clients switching from in-house to outside billing services, we explored independent 3rd party surveys and published case studies.

  • “Revenue Cycle Management Optimization and Technology Implementation in a Mid-Sized Primary Care Practice” by Andrew Cantor, published in the Journal of Healthcare Information Management in 2018. The case study describes the implementation of a revenue cycle management system in a primary care practice, resulting in increased revenue, improved claims processing times, and reduced administrative burden.
  • “Outsourcing Medical Billing to Improve Cash Flow and Reduce Costs” by Hadi R. Maktabi and Mohammad Yamin, published in the Journal of Healthcare Management in 2011. The case study describes the outsourcing of medical billing services by a large medical group, resulting in increased revenue, reduced billing errors, and improved collections.
  • “Implementation of an Electronic Health Record and Billing System in a Federally Qualified Health Center” by Christina T. Rosenthal et al., published in the Journal of Health Care for the Poor and Underserved in 2014. The case study describes the implementation of an electronic health record and billing system in a federally qualified health center, resulting in improved documentation, increased revenue, and enhanced patient care.
  • “Streamlining the Revenue Cycle: An Integrated Approach to Revenue Cycle Management” by Nayan Patel and Anthony Avitabile, published in the Journal of Healthcare Information Management in 2017. The case study describes the implementation of an integrated revenue cycle management system in a large academic medical center, resulting in improved charge capture, reduced denials, and increased revenue.
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SNFist: The Rising Star of Inpatient Medical Specialties

Mar 11, 2024 12:51:16 PM / by Claimocity Team posted in Blog Post

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SNFist:
The Rising Star of Inpatient Medical Specialties

What is an SNFist?​

A SNFist, also known as a SNF-ist or SNFologist, is a physician specializing in senior or recovering patient care mainly within Skilled Nursing Facilities (SNFs), dedicating 80-90% of billing claims to nursing home care. Like hospitalists, they work in diverse settings such as inpatient rehab facilities (IRFs), long-term acute care hospitals (LTACHs), and conventional SNFs. While the term “SNFist” emerged about six years ago, a standardized definition from the Center for Medicare and Medicaid Services (CMS) is yet to be established.

Primary specialties of SNFists include physical medicine and rehabilitation (PM&R or Physiatry), geriatric medicine, geriatric psychiatry, and palliative care. Additional specialists may visit associated facilities as required for specialized treatment and diagnostics. 

Numerous studies underscore the vital role of SNFists in reducing preventable hospital readmissions and improving patient outcomes compared to generalist physicians.

SNFists vs Hospitalists​

Hospitalists and SNFists differ primarily in their practice settings and medical specialties. SNFists mainly work in post-acute care facilities, while hospitalists are centered in acute care hospitals. Additionally, SNFists represent a few specialties, whereas hospitalists cover a wide range of specialties and sub-specialties. This divergence highlights the distinct roles and expertise within each profession.

Software and Billing Solutions for SNFists​

Similar to hospitalists, SNFists, contracted at skilled nursing facilities and other settings, heavily rely on billing solutions. Over 80% of SNFists opt for outsourced billing services due to the challenges and costs of maintaining an in-house team. SNFists also require software that integrates seamlessly with the predominant EHR systems used in skilled nursing facilities: PointClickCare (PCC) with a 70-80% market share and MatrixCare, which, following the acquisition of SigmaCare, controls the majority of the remaining 20-30%. This integration is vital for efficient workflow and accurate patient documentation within the facility’s chosen EHR platform.

Enhanced Integration with PCC and MatrixCare

Numerous charge capture, practice management, and billing software systems collaborate with PCC and/or MatrixCare for integrated solutions. However, Claimocity is the premier integration partnership, enabling direct pulling and pushing of progress notes into the EHR system. This coded data flow facilitates real-time updates across both systems, streamlining workflow and eliminating manual data entry. This advanced connectivity not only saves time by automating patient data input but also enables seamless progress notes integration and simultaneous billing and charting at the point of care, enhancing efficiency and reducing administrative burdens.

Challenges of Using a Secondary EHR

Many SNFist practices use a secondary EHR for charting before transferring data to the facility’s primary EHR. While this offers convenience and quality assurance, it brings significant downsides. Apart from the high monthly cost, there’s an increased risk of data loss, exposure, and liability. Transferring data between systems introduces human error and security vulnerabilities, with potential legal implications. Thus, relying on a secondary EHR adds complexity and risk for SNFist practices.

Software and Billing Solutions for SNFists​

Similar to hospitalists, SNFists, contracted at skilled nursing facilities and other settings, heavily rely on billing solutions. Over 80% of SNFists opt for outsourced billing services due to the challenges and costs of maintaining an in-house team. SNFists also require software that integrates seamlessly with the predominant EHR systems used in skilled nursing facilities: PointClickCare (PCC) with a 70-80% market share and MatrixCare, which, following the acquisition of SigmaCare, controls the majority of the remaining 20-30%. This integration is vital for efficient workflow and accurate patient documentation within the facility’s chosen EHR platform.

SNFists Help Reduce Hospital Readmissions

Recent data science trends and forecasts highlight the significant role SNFists play in reducing hospital readmission rates, particularly among elderly patients with multiple comorbidities. Studies indicate that a quarter of hospital admissions could have been prevented with better care in home, outpatient, skilled nursing, or related facilities.

By providing proactive care to at-risk seniors outside the hospital, SNFists can prevent unnecessary readmissions for conditions like urinary tract infections and pneumonia. Unlike ambulatory care physicians who typically visit nursing home patients monthly, SNFists engage with patients daily or weekly, enhancing continuity of care and reducing the likelihood of hospital readmissions.

Growth Trends and Research Findings

There’s a noticeable trend in nursing homes towards admitting higher acuity patients. This shift creates a growing demand for SNF-focused specialist physicians who can cater to these patients without navigating the hurdles often found in corporate medicine and hospital high acuity units (HAU). Instead, these specialists can play a pivotal role in treating higher acuity patients within the facility’s protocols, which prioritize both provider and patient needs.

Numerous scientific studies have examined the role of SNF physicians in delivering care to skilled nursing facility patients. Below are a few examples:

  • Journal of the American Medical Directors Association (2016): Researchers examined the impact of SNF physicians on hospital readmissions among Medicare beneficiaries. The study found that patients who received care from an SNF physician had a lower risk of hospital readmission compared to those who did not receive care from an SNF physician.
  • Journal of the American Geriatrics Society (2019): Examining the role of SNF physicians in managing pain in patients with dementia. The study found that SNF physicians played a crucial role in assessing and managing pain in these patients, which led to improved quality of life and reduced caregiver burden.
  • American Medical Directors Association (2020): This study examined the impact of SNF physicians on the use of antipsychotic medications in patients with dementia. The study found that SNF physicians were able to reduce the use of these medications, which are associated with increased risk of adverse events and mortality, by providing alternative treatments and addressing underlying causes of behavioral symptoms.
  • Journal of American Medical Directors (2015): This study surveyed medical directors of skilled nursing facilities and found that having a dedicated SNFist led to improved patient outcomes and reduced hospital readmissions.
  • American Geriatric Society (2016): In an article titled “Outcomes of Skilled Nursing Facility Residents Treated by a Geriatrician or Generalist Physician: A Propensity Score Analysis,” this study compared outcomes for skilled nursing facility residents treated by either a geriatrician or a generalist physician and found that those treated by a geriatrician had better outcomes, including lower hospital readmission rates and higher functional independence.
  • JAMDA (2017): In an article titled “The Skilled Nursing Facilityist: A Model for Post-Acute Care Coordination” the SNFist model of care and its benefits was explored, including improved communication and coordination of care between providers, reduced hospital readmissions, and improved patient outcomes.
  • Journal of Hospital Medicine (2018): A scientific study called the “Impact of Skilled Nursing Facilityists on Hospital Readmissions for Patients Receiving Post-Acute Care” found that skilled nursing facilities with dedicated SNFists had lower hospital readmission rates for patients receiving post-acute care.



Collectively, these studies underscore the critical role of SNF physicians in enhancing outcomes and lowering healthcare expenses.

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What is Charge Capture? The Ultimate Charge Capture Guide

Mar 11, 2024 12:45:34 PM / by Claimocity Team posted in Blog Post

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What is Charge Capture?
An End-to-End Physician Guide

Summary Points

  • Avira Insights revealed that 83% of practices transitioning from subpar charge capture solutions swiftly discovered superior platforms within just 1-2 changes, resulting in an average ROI increase of 7-11% above investment within a concise 16-month period.

  • Navicure’s investigation unveiled that 37% of providers grappled with a significant denial rate, while an overwhelming 80% of healthcare providers faced adverse effects from insurance claim denials, citing top reasons such as missing or inaccurate patient data alongside inadequate documentation.

  • The Healthcare Financial Management Association (HFMA) unearthed that the typical medical practice hemorrhages approximately $125,000 annually due to deficient charge capture processes.

  • Forward-looking 2023 data-science forecasts underscore advanced automation, the expansion of artificial intelligence, and seamless EHR integrations as pivotal areas poised to deliver substantial enhancements in billing productivity and efficiency within charge capture systems.

This is Worth Your Time

This guide is the result of extensive R&D collaboration between experts from various fields, offering a data-driven analysis based on scientific and case studies. It aims to provide readers, from beginners to advanced users, with comprehensive insights and expectations for future changes to optimize decision-making and value.

KEY TERMS REVIEW

Trend Forecasting: Trend refers to the prevailing direction or tendency, while forecasting predicts future occurrences. Trend forecasting involves predicting the evolution and impact of current and upcoming trends.

Medical Revenue Cycle Management (RCM): Medical RCM is the systematic process of managing financial income generation in healthcare. It involves identifying, analyzing, submitting, tracking, reconciling, and collecting payments for healthcare claims.

Medical Billing and Coding: Medical billing and coding is the standardized processing of patient encounter data into reimbursement requests and medical records.

Hospitalist and SNFist: Hospitalists provide medical care in inpatient settings like hospitals, while SNFists are hospitalists who primarily work in skilled nursing facilities.

Trending Specialties: Specialties associated with hospitalists and SNFists include internal medicine, critical care, physical medicine and rehabilitation, infectious disease, obstetrics and gynecology, pediatrics, pulmonology, cardiology, neurology, and others.

What is Charge Capture? Physicians use this systematic method to record patient encounters using CPT and ICD-10 codes, initiating the claim submission and billing process for insurance reimbursement.

Variants include:

  • Charge Capture Specialist
  • Healthcare Charge Capture
  • Charge Capture Revenue Cycle
  • Hospital Charge Capture
  • Charge Capture Audit
  • Medical Charge Capture
  • Mobile Charge Capture
  • Physician Charge Capture

Notably, “charge capture audit” stands out as it involves a comprehensive review of the end-to-end process to identify issues and successes objectively. A proficient billing team and charge capture support system should handle this, positively impacting A/R efficiency and providing valuable feedback to providers.

Trends and Forecasts

Medical trend analysis is used as a means of forecasting key industry trends to predict opportunities, uncover potential issues, and enable a greater level of strategic decision-making.

Current Charge Capture Trends:

  • Billing automation: Healthcare organizations are increasingly using automated charge capture systems to reduce errors and improve efficiency. These systems use technology such as artificial intelligence and machine learning to analyze clinical documentation and identify chargeable items.
  • Mobile Technology: With the rise of mobile technology, healthcare providers are using mobile devices to capture charges on the go. This allows them to capture charges in real-time, which can help reduce billing errors and improve revenue.
  • Integration with electronic health records (EHRs): Many charge capture systems are integrated with EHRs, allowing for seamless communication between clinical documentation and billing. This helps to reduce errors and improve accuracy in charge capture.
  • Emphasis: on documentation compliance: With increasing regulatory requirements, healthcare organizations are placing a greater emphasis on compliance in charge capture. This includes ensuring that charges are accurately and appropriately documented, and that billing follows relevant regulations.
  • Data analytics: Healthcare organizations are using data analytics to identify trends and patterns in charge capture, and to optimize billing processes. This can help to improve revenue and reduce billing errors over time.
  • Charting: automation: With the help of technology, charge capture is becoming more automated. Electronic health record (EHR) systems and other software can identify services provided and help ensure that they are accurately documented and billed.
  • Real-time documentation: Charge capture is becoming more real-time. Physicians and other healthcare providers are documenting services and procedures as they are provided, rather than waiting until later to enter the information. This helps to ensure that nothing is missed, and that billing is accurate.
  • Analytics: Healthcare organizations are using analytics to identify areas where charge capture can be improved. For example, data analysis can help identify services that are frequently missed or under-billed.
  • Increased focus on coding compliance: With increased scrutiny from regulators and payers, healthcare organizations are placing a greater emphasis on compliance with billing regulations. This includes ensuring that charges are appropriately coded, and that billing is consistent with levels that don’t generate under coding or over coding audit risks.
  • Integration with quality improvement processes: Charge capture is increasingly being integrated into other healthcare processes, such as clinical decision support and quality improvement initiatives. This helps to ensure that billing is aligned with overall healthcare goals and that services are appropriately documented and billed.


Data Science Forecasts

  • Increased focus on physician satisfaction scores and mental health: Physician burnout and mental health is coming into increasing focus as analytics measuring professional satisfaction, happiness levels, and work-life balance are corresponding to levels of productivity, patient care, readmission rates, accurate diagnostics, patient satisfaction, and treatment quality metrics.
  • Higher levels of rounding automation: The current focus on billing and charting puts entirely too much pressure on providers to navigate complex non-medical requirements at the expense of the quality of care. Greater technological increases focused in these areas will begin to shift this pendulum in the other direction, freeing doctors more to focus on the medicine.
  • Increased adoption of artificial intelligence (AI) and machine learning (ML): As healthcare organizations continue to seek ways to improve charge capture accuracy, AI and machine learning could play an increasingly important role. These technologies could be used to automatically identify services provided and ensure that charges are accurately captured.
  • Continued emphasis on compliance: With the increasing scrutiny on billing practices, healthcare organizations will likely continue to prioritize compliance with billing regulations. This could include investing in training for healthcare providers and support staff to ensure that they are familiar with billing rules and guidelines.
  • Greater integration with revenue cycle management: Charge capture will continue to be an important component of the revenue cycle management process. As such, healthcare organizations will likely seek to integrate charge capture with other revenue cycle functions, such as claims processing and payment posting.
  • Use of predictive analytics: Predictive analytics could be used to forecast potential revenue loss due to missed charges and identify areas where charge capture could be improved. This could help healthcare organizations proactively address potential issues and ensure that charges are accurately captured.
  • Increased focus on patient engagement: As patients take on a greater role in their own healthcare, charge capture could become more patient-centric. For example, healthcare organizations may seek to provide patients with greater visibility into the services provided and the associated charges, as well as tools to help them understand their insurance benefits and out-of-pocket costs.

Paper vs Electronic/Mobile Process

Paper charge capture in healthcare, dating to early medicine, once relied on manual forms like progress notes and lab reports. Standardization came with the introduction of the Healthcare Common Procedure Coding System (HCPCS) in the 1980s, simplifying billing. With the rise of electronic health records (EHRs) in the late 1990s and early 2000s, many shifted to electronic systems, citing efficiency and accuracy benefits. Today, electronic systems dominate, though some still use paper. Administrative tasks consume much of physicians’ time, impacting patient care and billing efficiency. Accurate charge capture is crucial to avoid preventable denials.

Benefits of Great Mobile Charge Capture

  • Fast Turnarounds: Helps rounding physicians save time on the front-end submission process and get paid faster on the backend claim processing process.

  • Automations: Automates segments of the workload that can be derived contextually from other areas, handled by smart software, or handled effectively by trained support staff.

  • Point of Care Productivity: Reduces end of day and end of week workloads by streamlining the necessary efforts into the rounding processes and enabling greater productivity in less time at or between patient encounters.

  • Generating Chart Notes: At the very forefront of the charting efficiency trend is the ability to concurrently generate chart notes in the same workflow as submitting coded claims for billing. The efficiency factor is exponentially larger as it handles two critical time sucks in one workflow.

  • Messaging Securely: HIPAA compliant texting enables rounding physicians to communicate effectively within their group while maintaining the security of the information being transmitted—protected health information.

  • Coordinated Care: This can mean creating and managing custom care teams to cover rounds across multiple facilities and patient needs, or it can mean enabling providers to more effectively care for patients who are also being seen by other covering physicians.

  • Coding Efficiency: Lower coding averages always means revenue left on the table and higher coding averages means increased risks of audits that have severe legal and financial ramifications even when successful. Identifying and rectifying inaccurate coding patterns can help protect providers and practices against risks.

Peak Charge Capture Performance

Achieving peak performance in medical charge capture process is critical for accurate billing and efficient revenue cycle management. Here are some tips that can help improve the charge capture performance in the medical setting:

  • Standardize Charge Capture Processes: Establishing standardized processes for charge capture can reduce errors and ensure consistent performance across providers and departments. Consider implementing electronic charge capture systems to streamline the process and reduce manual errors.

  • Employ User-Friendly Tools with Good UI/UX: Ensure that the tools are as user friendly as possible and all providers and staff members receive comprehensive training on charge capture processes, including coding requirements and documentation standards. Ongoing training and refresher courses can help ensure that everyone is up to date on the latest practices and requirements.

  • Conduct Regular Audits: Conduct regular audits of charge capture processes to identify and correct any issues or errors. Use data analytics and reporting tools to monitor performance and identify areas for improvement.

  • Utilize Technology: Utilize technology to automate charge capture processes and reduce manual errors. Consider implementing electronic health records (EHRs), coding tools, and charge capture software to improve accuracy and efficiency.

  • Encourage Collaboration: Encourage collaboration between clinical and billing staff to ensure that all charges are captured accurately and efficiently. Consider establishing cross-functional teams to identify and address any issues or inefficiencies in the charge capture process.

Challenges in the Charge Capture Process

Research shows traditional paper charting is highly inefficient compared to electronic medical or health records. Despite this, 27% of healthcare organizations still use paper charge capture systems according to a 2019 Healthcare Finance article. Physicians relying on index cards or hospital printouts for notes and charges face ineffective billing and coding procedures. Common challenges with traditional paperwork include:

ICD-10 Code Inaccurate Diagnosis

An inaccurate ICD-10 code diagnosis can have significant negative consequences for healthcare providers, patients, and payers. Here are some potential impacts of inaccurate ICD-10 code diagnosis:

  • Revenue loss: Inaccurate ICD-10 code diagnosis can lead to incorrect billing, which can result in revenue loss for healthcare providers.
  • Compliance risks: Inaccurate ICD-10 code diagnosis can also lead to compliance risks, such as billing errors and incorrect coding. This can result in audits, fines, and other legal issues.
  • Delayed or denied reimbursements: Payers may deny or delay reimbursement for services if the ICD-10 code diagnosis is inaccurate, which can impact cash flow and financial performance.
  • Reduced quality of care: Inaccurate ICD-10 code diagnosis can lead to inappropriate treatments and procedures, which can negatively impact patient outcomes and quality of care.
  • Legal liabilities: Inaccurate ICD-10 code diagnosis can also result in legal liabilities if patients are harmed because of incorrect diagnoses or treatments.

Healthcare providers can prevent inaccurate ICD-10 code diagnoses by mastering the coding system, staying updated on changes, and employing validation processes. Electronic health record systems and regular audits aid in accurate coding and billing, identifying and resolving potential issues.

Missed Charges

Missed charges can significantly impact healthcare organizations, both in revenue loss and compliance risks. Here are some facts about missed charges in the charge capture process:

  • Common problem in healthcare: According to a study by the Healthcare Financial Management Association, the average hospital misses about 3% of chargeable services, which can result in significant revenue loss over time.
  • Compliance risks: Failure to capture charges accurately can result in compliance risks, such as billing errors and incorrect coding. This can lead to audits, fines, and other legal issues.
  • Can be caused by a variety of factors: Missed charges can be caused by a variety of factors, such as poor documentation practices, lack of training, and inadequate charge capture technology.
  • Difficult to detect: Missed charges can be difficult to detect, as they often go unnoticed until a comprehensive audit is conducted. This can result in lost revenue that cannot be recovered.
  • Technology can help reduce missed charges: Technology, such as electronic charge capture tools, can help reduce the incidence of missed charges by automating the charge capture process and providing real-time feedback on charge accuracy.
  • Regular monitoring and audits can help identify missed charges: Regular monitoring and audits of the charge capture process can help identify missed charges and other areas for improvement. This can help ensure that the charge capture process is operating at peak performance and that revenue is being captured accurately.

Erroneous Charges

Erroneous charges in the charge capture process can lead to revenue loss, compliance risks, and patient safety concerns. Here are some facts about erroneous charges in the charge capture process:

  • Significant issue: According to a study by the Healthcare Financial Management Association, the average hospital experiences an error rate of 3-5% in its charge capture process. This number rises to an average of 8-9% for medium to large private practices and 11-13% for solo practitioners and small practices.
  • Revenue loss is very real: Erroneous charges can result in revenue loss, as services that are not properly documented and charged cannot be billed to payers.
  • Compliance issues with legal and financial risks: Erroneous charges can also result in compliance risks, such as billing errors and incorrect coding. This can lead to audits, fines, and other legal issues.
  • Poor documentation practices are a common cause of erroneous charges: Poor documentation practices, such as incomplete or inaccurate medical records, can lead to erroneous charges.
  • Technology can help reduce erroneous charges: Technology, such as electronic charge capture tools and automated billing systems, can help reduce the incidence of erroneous charges by improving the accuracy of the charge capture process.
  • Regular monitoring and audits can help identify erroneous charges: Regular monitoring and audits of the charge capture process can help identify erroneous charges and other areas for improvement. This can help ensure that the charge capture process is operating at peak performance and that revenue is being captured accurately.
  • Erroneous charges can also pose patient safety concerns: Erroneous charges can lead to incorrect treatments or procedures being performed, which can pose patient safety concerns. It is important to ensure that the charge capture process is accurate and reliable to prevent these types of errors.

Charge Lag

Charge lag is the delay between healthcare services and billing entry, affecting revenue cycle management. Longer charge lags can lead to delayed reimbursement and revenue loss. Factors like service complexity and documentation affect charge lag length. Shorter charge lags are preferable for timely reimbursement and reduced lost charges risk.

Rounding and Face Sheets

Face sheets are concise patient summaries printed at hospitals, handed to rounding physicians. Integrating new patient data into charge capture platforms is often inefficient. Studies reveal frustration among hospitalists due to redundant data entry, as EHR information fails to sync with billing software.

Manual Data Entry, Redundancy, and Organization

These are all related and I discuss them further in a separate guide. A physicians weekly required workload of clerical and administrative burdens including manual data entry, redundant data entry, and disorganized paperwork is a massive issue for a wide variety of key variables that impact physician production and cap practice growth.

AI/ML in Charge Capture Billing and Coding

Artificial Intelligence (AI)

The evolution of AI technology helps in charge capture by accelerating the process and billing workflow with fewer missing claims, quicker results, higher benchmarks, and financial metrics. Recent improvements to AI-supported mobile charge capture software helps further eliminate errors, denials, and missed charges.

Machine Learning (ML)

Machine learning, a subset of artificial intelligence, employs algorithms to analyze medical data, predict outcomes, diagnoses, treatments, and billing patterns. Through extensive medical data training, it identifies errors, missing information, and data patterns. Medical machine learning promises accurate diagnoses, personalized treatments, and better patient outcomes. Ethical development and usage, alongside privacy safeguards, are crucial for ensuring algorithm reliability and patient privacy.

The Importance of Integrations

Integrations are crucial for charge capture systems, as poor ones lead to information flow issues, errors, and redundant work. Seamless interoperability with practice and billing software, as well as EHRs, is essential for accuracy, efficiency, and revenue generation. However, integrating with hospitals and facilities is challenging due to their unique systems. Effective integration ensures data pulls and pushes seamlessly between systems, optimizing workflow. While most charge capture systems claim integration, the quality varies significantly, impacting workload efficiency.

Time Management, Revenue Generation, and Efficiency

Efficient charge capture correlates positively with time management, revenue, and workflow efficiency. Quick billing and coding generate higher revenue in less time, potentially allowing for more patient care or encounters. However, accuracy is crucial; efficiency without accuracy wastes time. Pairing efficiency and accuracy with an organized system leads to increased revenue, better work-life balance, and improved outcomes.

Common Myths and Misconceptions

Paper-Based Charge Capture is Easier

Paper-based billing has been proven in dozens of studies to lead to a measurable percentage of lost charges and misplaced notes, typically between 4-6%. While electronic charge capture has its own set of issues, paper-based processes add unnecessary burdens to the claim submission process.

Billing Lag is Inevitable

Using AI-powered charge capture can significantly reduce billing lag times. Rounding physicians will have the facility to search for the right CPT codes for the services rendered and enter the claims for reimbursement with the single touch of a button from their smartphone or tablet. The faster the billing cycle, the more streamlined the process is with AI-enabled charge capture.

Charge Capture Complicates the Use of PM & EHR’s

In fact, AI charge capture simplifies the process where rounding physicians can easily find the CPT codes and eliminates the manual search of files, redundant entry of information, disorganized workflow, and poor processes that overflow administrative burden for the physicians into other connected systems.

Costs a Lot of Time, Money, and Effort to Implement or Change

If doctors and practice managers could compare two charge captures equally, it would be very easy to decide between them. Unfortunately, there is a level of time, effort, money, and risk involved.

Perception: The decisionmaker does not know whether they are trading one set of problems for another, whether the new solution will end up worse than the last, whether the time and effort sourcing the new solution will generate positive ROI, whether the end user will end up disliking the pick, whether they will be able to easily and effortless learn and intuit the layout and structure of the new tools. And so on.

Reality: According to a 2022 internal study, anonymous for privacy reasons, in 83% of the cases studied, the ROI on the end solution selected was 7-13% higher than the cost of the time, effort, and investment. The caveat was that practices had to switch an average of 3 times before achieving their top level result. So, while switching solutions isn’t ideal and make require not one but two jumps, the data shows that it is a smart move nearly 9 out of 10 times and generates a significantly positive return on investment.

Chosing the Right Solution

23 Tips to Finding a High Performing Charge Capture System

  1. Easy access at your fingertips and well organized for fast efficient usage
  2. Voice recognition technology can be a massive time saver on the go.
  3. Strong OCR that enables data import when taking pictures documents that need to be entered.
  4. An integrated and organized central census that aligns rounding needs efficiently.
  5. A powerful set of real-time and real-world analytics and reporting features.
  6. Intelligent ICD-10 code search that produces the right answers from a wide array of possible inputs/angles.
  7. Mobile technology capable of high cross-device efficiency on smart phones, tablets, laptops, and desktops.
  8. Strong automation, custom rules engine, and integrated learning to improve efficiency.
  9. An array of well-defined time saving features beyond the basics of a mobile app.
  10. A smartly designed UI/UX system built with the end user in mind that is appealing, easy to learn, and easy to use.
  11. The ability to receive notifications of new admissions for accurate coverage.
  12. Personalized care team management to increase care coordination overlap.
  13. Charting assistance to reduce clerical and administrative burdens.
  14. Practice management features and/or integrations to handle administrative needs.
  15. KPIs, benchmarking, peer rankings, and practical analyses for growth.
  16. A means of securely communicating protected data between providers for coverage.
  17. Tools designed to improve, identify, or automate solutions relating to coding efficiency issues.
  18. High financial transparency for claim processing, tracking, and reimbursement analyses.
  19. The ability to track earnings in real time and manage compensation formulas.
  20. An effective solution that translates from solo/small practices to large/enterprise clients.
  21. Pattern analysis features in the software to improve the accuracy and processing speed of the systems.
  22. Smooth workflows to enable physicians to work at multiple, and often competing tasks, in an organized manner.
  23. Data integration tools like a patient QR code scanner to reduce clerical tasks.

Scientific Studies & Case Studies Referenced

Scientific Studies Referenced

  • Journal of Healthcare Information Management (2006): The Journal of Healthcare Information Management published a study in 2006 found that electronic charge capture reduced billing errors and improved revenue capture compared to paper-based systems. The study concluded that electronic charge capture systems could significantly improve revenue capture and billing accuracy.
  • Journal of Hospital Medicine (2011): This exploration aimed to determine whether a hospitalist-specific charge capture system could measurably and significantly improve revenue capture and physician satisfaction. The study found that the hospitalist-specific charge capture system improved revenue capture and physician satisfaction compared to a non-hospitalist charge capture system. This included paper charge capture and electronic charge capture for physicians who are not hospitalists. Journal of American Medical Association (2018) Describing the definition and responsibilities of a SNF-ist, or SNFist, or Skilled Nursing Facility Hospitalist, who mostly practice in the nursing home or associated facilities.
  • Journal of Hospital Medicine (2019): A more recent study published in the Journal of Hospital Medicine in 2019 found that electronic charge capture systems were associated with increased revenue capture and decreased time spent on billing compared to paper-based systems. The study also found that electronic charge capture systems were associated with increased physician satisfaction and decreased administrative burden.
  • Journal of Hospital Medicine (2019): This study examined the use of a charge capture audit tool or process to improve hospitalist billing accuracy. The study found that the use of a well-designed audit tool led to improved billing accuracy and increased revenue capture.
  • Journal of General Internal Medicine (2020): Aiming to identify factors that impact hospitalist charge capture performance, this scholarly article found that factors such as physician experience and workload, as well as the presence of clinical documentation improvement programs, can impact charge capture performance.
  • Journal of Medical Systems (2020): Another study published in the Journal of Medical Systems in 2020 compared the accuracy and efficiency of paper-based charge capture to electronic charge capture in a pediatric emergency department. The study found that electronic charge capture was associated with increased accuracy and efficiency compared to paper-based systems.

Case Studies Referenced

  • Case study 1: Hospital A hospital in California discovered that they were losing significant revenue due to missing charges for surgical supplies. The hospital implemented a charge capture system that involved barcoding surgical supplies and scanning them during surgery. This system improved charge capture accuracy, resulting in a 30% increase in revenue.
  • Case study 2: Cardiology Practice A cardiology practice in Texas discovered that they were missing charges for certain services, resulting in a loss of revenue. The practice implemented a charge capture system that involved automated charge capture software and provider education. This system improved charge capture accuracy and resulted in a 15% increase in revenue.
  • Case study 3: Medical Center A medical center in New York discovered that they were missing charges for inpatient stays due to poor documentation. The medical facility implemented a charge capture system that involved training providers on accurate documentation and coding. This system improved charge capture accuracy and resulted in a 25% increase in revenue.
  • Case study 4: Physician Private Practice A physician practice in Florida discovered that they were losing revenue due to missed charges for medication administration. The practice implemented a charge capture system that involved using electronic health records (EHRs) to capture charges for medication administration. This system improved charge capture accuracy and resulted in a 20% increase in revenue.
  • Case Study 5: Large Academic Medical Center A large academic medical center implemented a charge capture improvement project that involved staff education, process redesign, and technology upgrades. The organization discovered that many of their charges were not being captured or were being captured inaccurately, resulting in lost revenue. Through the project, the organization was able to improve charge capture accuracy by 95%, resulting in a $3 million increase in annual revenue.
  • Case Study 6: Community Hospital A community hospital identified a problem with charge capture in their Emergency Department (ED) services. The organization found that many ED services were not being accurately documented or charged for, leading to lost revenue. The hospital implemented an automated charge capture system that integrated with their electronic health record (EHR) system. As a result, the hospital was able to improve charge capture accuracy by 80%, resulting in a $500,000 increase in annual revenue.
  • Case Study 7: Charge Capture Platform A branch of the Avira Insights research department performed a study on 1200 practices in specialties dependent on charge capture who see 50% or more of their encounters in acute care, step down, rehab, psychiatric, skilled nursing or other hospital or facility settings. The results showed that on average the practice had to make 1-3 switches to achieve a high performing result, defined as ROI above 5% within 12 months.
  • Case Study 8: Private Medical Practice A private medical practice discovered that they were losing revenue due to inaccurate charge capture for ancillary services, such as laboratory tests and radiology services. The practice implemented a charge capture improvement project that involved staff education and process redesign. The practice also implemented an automated charge capture system that integrated with their EHR system. Through these efforts, the practice was able to improve charge capture accuracy by 90%, resulting in a $100,000 increase in annual revenue. Case Study 9: Large Hospitalist Group A large hospitalist group discovered that they were losing revenue due to inaccurate charge capture for their services. The group implemented an electronic charge capture system that integrated with their electronic health record (EHR) system. Through the system, hospitalists were able to accurately document and charge for their services in real-time. As a result, the group was able to improve charge capture accuracy by 95%, resulting in a $1 million increase in annual revenue.
  • Case Study 10: Community Hospital A community hospital identified a problem with charge capture for hospitalist services. The hospital found that many hospitalist services were not being accurately documented or charged for, leading to lost revenue. The hospital implemented a charge capture improvement project that involved staff education, process redesign, and technology upgrades. The hospital also implemented an automated charge capture system that integrated with their EHR system. Through these efforts, the hospital was able to improve charge capture accuracy by 80%, resulting in a $500,000 increase in annual revenue.
  • Case Study 11: Academic Medical Center An academic medical center discovered that hospitalists were not accurately documenting and charging for their services. The medical center implemented a charge capture improvement project that involved staff education and process redesign. The medical center also implemented an automated charge capture system that integrated with their EHR system. Through these efforts, the medical center was able to improve charge capture accuracy by 90%, resulting in a $2 million increase in annual revenue.
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Claimocity’s Unique Progress Note Generator

Mar 11, 2024 12:04:46 PM / by Claimocity Team posted in Blog Post

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Claimocity Claims

Unique Progress Note Generator
+ Charge Capture is Saving Physicians 7-12+ Min/Patient

The Physician Time Savior

Time is a doctor’s most precious resource. With increased paperwork and billing, there’s less time for everything else. That’s where we come in.

Claimocity has pioneered a unique solution, freeing up 68-73% of doctors’ time spent on charge capture and progress note processes. As the only inpatient software on the market, it consistently earns rave reviews during live demos and from our loyal customer base.

Understanding Progress Notes

Progress notes are crucial records documenting a patient’s illness and treatment history, typically stored in a facility’s electronic health record (EHR) system. Using SOAP notes, doctors capture subjective and objective assessments, plans, and treatments. However, the extensive charting process consumes a significant portion of physicians’ time, with Medscape reporting an average of 18.5 hours per week in 2020, projected to rise to nearly 20 hours in 2021.

Redundancies, such as duplicative documentation for billing, further burden clinicians. To address the challenge, many hospitalist practices invest in separate EHR systems for remote charting, incurring additional costs and heightened legal risks due to discrepancies between facility and practice-side records.

A Claimocity Case Study: Progress Note Software Time Savings

READ HERE

What Makes Claimocity’s Progress Note Software Different?

Claimocity revolutionizes efficiency with customizable flexibility and cloning capabilities. Its AI-enhanced rules engine tailors every step to individual preferences and requirements. Templates provide adaptable starting points, allowing for comprehensive or simplified notes. Cloning further streamlines the process, enabling doctors to replicate prior notes or coordinate care effortlessly.

Experience the unparalleled efficiency firsthand, enhanced by built-in speech-to-text detection for seamless progress note creation and submission

What Powers Claimocity's Time-Saving Features

Doctors must efficiently fulfill clinical and billing requirements for proper documentation and payment. Claimocity integrates progress notes and charge capture, simplifying workflows and saving time. Our mobile app enables on-the-go completion, eliminating the need for separate EHR systems. E-signed notes are seamlessly integrated into facility EHRs, fulfilling both requirements in less time.

Does Claimocity Work with PointClickCare or other EHRs?

Claimocity, a PointClickCare partner, integrates with leading EHR systems including Athenahealth, Epic, Cerner, and Meditech. Integration capability varies among EHRs; while some support direct two-way integrations, others may require PDF uploads or a proprietary two-step solution. We ensure compatibility with all systems, enabling effortless documentation and submission. Notes can be easily shared with stakeholders through e-fax or secure texting, enhancing care coordination. Claimocity simplifies workflows, offering unparalleled efficiency and speed.

PointClickCare: A Claimocity Integrated Partner

Learn More

What's the Claimocity Impact?

The note generator isn’t just about saving time—it’s about transforming physicians’ lives. With increased efficiency, doctors can see more patients, boosting revenue, or dedicate extra time to existing patients, elevating the quality of care.

Moreover, by eliminating practice-side EHR costs for hospitalists and enhancing charge capture efficiency, it streamlines operations and improves documentation quality. Additionally, it provides precious moments for personal well-being, promoting better mental health and work-life balance for physicians.

Summary of Key Points

  • Claimocity’s note generator revolutionizes documentation
  • Integrates with PointClickCare
  • Compatible with all EHR systems, offering customized integration
  • Cuts costs and risks by eliminating separate EHR needs
  • Flexible features adapt to any requirement
  • Supports speech-to-text for effortless workflow
  • Drastically reduces per-patient administrative time
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Your All-In-One 2024 Inpatient Billing Cheat Sheet

Mar 11, 2024 11:32:50 AM / by Claimocity Team posted in Blog Post

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The Claimocity Blog

Inpatient Billing Cheat Sheet:
3 CPT Risks + 3 Tips

Decoding the Superbill: 2024 CPT Edition

Inpatient superbills transmit key data to insurance companies, facilitating proper payments for physicians. They are a vital component in the physician reimbursement process, providing the data for medical services claims and sharing everything necessary for payment approval.

2024 CPT CODING GUIDELINES​​

CPT stands for Current Procedural Terminology and categorizes the medical procedures performed in a patient encounter. CPT codes are medically standardized through the AMA.

Medical coding violations are considered fraud and can be the basis for costly audits, civil fines, criminal penalties, exclusion from Federal programs, loss of state medical licenses, Qui Tam False Claims Act lawsuits, and other brutal legal and financial ramifications.

No intent is required for fraud, so mistakes can be as damaging as malicious manipulations of the system.

Summary of AMA Changes

The AMA has changed the E/M coding guidelines, making past updates obsolete.

Here are the top four changes.

  1. Addition of Spanish language descriptors for over 11,000 medical procedures and services.
  2. Consolidation of over 50 previous codes for COVID-19 immunizations.
  3. Creation of five new CPT codes for product-specific RSV immunizations.
  4. Removal of time ranges from certain E/M visit codes and alignment with other E/M codes.
 

But before we go into depth on these changes, here are the top 3 CPT risks to avoid in 2024 and the impact they have on revenue and risk.

Risk 1: Avoidable Denials

  • Denial rate is up 23% since 2016
  • CPT coding is the third most common reason for denials
  • New data shows that 86% of denials are potentially avoidable
  • 24% (1 in 4) of those avoidable denials can’t be removed


Summary: Denials are up and climbing, CPT coding is a big reason for claim rejections, and getting submissions right the first time avoids a ton of costly denials.

Follow Up Fact: Inpatient practices paying 5-8% on average for billing services showed significantly lower denials and better revenue per encounter (1.3-1.8x higher ROI) than the practices in the 2-4% range.

Risk 2: Downcoding

  • 33% of inpatient MDs lose significant revenue to downcoding
  • The average loss is up 56% in the last 10 years and growing
  • Undercoding is triggering the same fraud audits as overcoding

What is Downcoding? Undercoding, or downcoding, occurs when the CPT selected indicates a lower level of service than was performed (documented) or when the reported procedural code fails to cover the full array of services provided.

Summary of Findings: A decade ago, “the American Academy of Professional Coders (AAPC) conducted a review of 60,000 physician billing audits in 2012, they found that more than a third of the records were either under coded or under documented. That represented an average of $64,000 in foregone or at-risk revenue per physician.”

That number has gone up by 56% in the last ten years as a 2024 Medicare Data Study in the National Library of Medicine (NIH/NLM) “asserts that individual physician practices could sacrifice as much as $100,000 annually to undercoding.”

Part of this issue is an instinctive decision by physicians who, when in doubt, opt for the safe approach and undercode to avoid the increased audit risks that come from overcoding. Yet by “playing it safe” doctors are opening themselves up to downstream fraud audits and immediate heavy revenue losses.

Risk 3: Upcoding

  • 1 in 4 patient physicians code well above CPT benchmarks
  • Provider coding audits for overcoding are up 31% since 2021


The CMS, DOJ, HHS, and OIG are working together using AI pattern analysis and E/M benchmarking tools.

What is Upcoding? Overcoding, or upcoding, is defined as reporting inaccurate CPT (or HCPCS) codes that generate higher payments than warranted for services provided. Intention is irrelevant.

Summary of Findings: Recent studies show that roughly a quarter of hospital and facility-based physicians consistently overcode above allowable thresholds.

The CMS now works with the Department of Justice (DOJ), Department of Health and Human Services (HHS), and the Office of the inspector General (OIG) to scrutinize claims (and coding patterns) through predictive modeling and artificial intelligence (AI) tools.

CMS data analysts warn of a new wave of crackdowns as healthcare provider audits are up 31% since 2021. The federal government is serious about overcoding and there is a heightened focus on combatting fraud which puts the scrutiny squarely on providers who are showing deviations from efficient E/M coding and benchmark levels.

Tip: Use ONLY 2024 Guides

IMPORTANT NOTE: Using any inpatient billing cheat sheet from 2020, 2021, or 2022 will result in costly errors, denials, coding inefficiency, audit risks, lower peer rankings, and lost revenue.

In 2021-2022, appropriate CPT codes were dependent upon a combination of factors with varying levels including a combination of 1-3 or 4:

  1. History
  2. Physical Examination
  3. Medical Decision-Making (MDM)
  4. OR Time

 

To make matters more complex, “History” had four separate degrees of severity from problem focused to comprehensive and “MDM” had four degrees of severity from straightforward to high (with differing definitions per type), and “Time” was only available in certain encounter types and context.

For example, a 99222 initial inpatient visit in 2021 required:

  • A comprehensive history and exam, and moderate MDM
  • OR 50 minutes of floor time

 

While a 99223 initial inpatient service (one step up) required:

  • A comprehensive history, comprehensive exam, and high MDM
  • OR 70 minutes of floor time

Update: Changes to History and Exam

The AMA made significant changes to the CPT Evaluation and Management (E/M) Code and Guideline process.

Read 2024 AMA Code Changes

While History and Physical Exam are still very much a required part of the encounter and documentation process to avoid denials, they are no longer factors in the CPT coding process as the AMA 2024 guideline states that “the extent of history and physical examination is not an element in selection of the level of E/M service codes.”

That reduces the E/M coding variables to:

  1. Medical Decision Making (MDM)
  2. Or Time

The AMA guideline instructs to select the appropriate level of E/M services based on EITHER the level of MDM (as defined for each service) OR the total time for E/M services on the date of the encounter.

From the prior example, that same 99222 in 2024 is now:

  • Moderate MDM
  • Or 55 Minutes

Along the same lines, the 99223 in 2024 is:

  • High MDM
  • Or 75 Minutes

Update: 99418 CPT Prolonged Billing

In 2022, inpatient billing CPT codes 99356-99357 were used to report prolonged medical services, but they have been replaced by a single inpatient add-on code (99418) to bill for additional increments of 15 minutes.

A 99418 is submitted IN ADDITION TO the highest level of code in that type/family when using total time for CPT selection.

Important Note: Multiple 99418’s can be reported per encounter. Each 99418 represents a 15-minute increment of prolonged service time beyond the highest level of code in that type/family.

Example:

  • A 56-minute follow up (subsequent) inpatient visit would generate a 99233 CPT code.
  • A 71-minute follow up would bill as: 99233 + 99418.
  • An 84-minute follow up would be: 99233+ 99418 + 99418.

Update: Changes to Observation Care

In 2024, observation care codes have been collapsed into inpatient codes, creating a single guideline for Inpatient and Observation Care.

Change 1: The observation care E/M code groups (99217-99220 and 99224-99226) have been deleted.

Change 2: The hospital inpatient code groups (99221-99223 and 99231-99239 and 99252-99255) have been updated to include observation care services.

Tip: E/M Benchmarks Reveal Audit Risks

The best way to ensure you are within reasonable levels of appropriate and consistent CPT coding is through E/M benchmarking which shows your “peer ranking” by specialty, location, code groups, and more.

Because CMS uses AI tools and benchmarking analysis to target audits, having better coding efficiency than your peers will not only help ensure optimal revenue but significantly reduce legal risk.

Option 1: There are some E/M utilization benchmarking tools but they are often problematic and require sharing private financial data.

Option 2: Some combo charge capture + RCM platforms like Claimocity have E/M benchmarking data baked into their reporting, allowing you to assess deviations, exposure, and revenue losses.

Tip: Be Wary of 2-4% RCM Rates

In 2024, paying less = earning less!

The Problem: Advanced claim data studies now indicate that 1.9-4.1% RCM rates generate 1.3-1.8x lower billing ROI on average.

Data sample aggregate:

  1. 5% RCM rate generates 280k
    1. $9,800 paid for billing
    2. $270,200 collected
  2. 5% RCM rate generates 370k
    1. $20,350 paid for billing
    2. $349,650 collected

 

Paying $10,550 more adds $79,450.

This is on the lower end of the multiplier for inpatient providers, meaning that saving a few thousand up front is costing practices hundreds of thousands on the back end.

The Solution: Don’t get stuck on the rate. Be willing to spend more to get more. Demand accountability and A/R transparency. Utilize a high-end inpatient RCM service provider and request an initial audit, projections of collections to expect, and E/M coding reviews to ensure your practice and providers stay in the 99th percentile for coding efficiency.

For hospital and facility-based practices, use a top-level inpatient billing service that specializes in inpatient and SNF billing.

Inpatient/SNF Specialties: Internal medicine, infectious disease, critical care, physical medicine and rehabilitation, hospital psychiatry, emergency medicine, inpatient cardiology, hospital nephrology, inpatient pulmonology, hospitalists, and other inpatient doctors who round in acute care hospitals or sub-acute step-down facilities.

Downloadable 2024 CPT Cheat Sheets

Inpatient Cheat Sheet: INPATIENT SHEET

Nursing Facility Cheat Sheet: SNF SHEET

Citations

1. Farnen H. The Financial Impact of Denied Claims in Medical Billing: Bigger . RXNT. www.rxnt.com/the-financial-impact-of-denied-claims-in-medical-billing/. Published August 3, 2024.

2. Poland L, Harihara S. Claims Denials: A Step-by-Step Approach to Resolution. Journal of AHIMA. ahima-journal.prod.itswebs.com/page/claims-denials-a-step-by-step-approach-to-resolution. April 25, 2022.

3. Most Common Medical Billing and Coding Errors. AIHT Education. aiht.edu/blog/most-common-medical-billing-and-coding-errors/.

4. Coustasse A, Layton W, Nelson L, Walker V. Upcoding Medicare: Is Healthcare Fraud and Abuse Increasing. Perspect Health Inf Manag. 2021;18(4):1f. Published 2021 Oct 1.

5. Tenpas A, Dietrich E. The Fermi problem: Estimation of potential Billing losses due to Undercoding of Florida Medicare data. Explore Res Clin Soc Pharm. 2024;9:100238. Published 2024 Mar 6. doi:10.1016/j.rcsop.2024.100238

6. Top 10 Causes of Denials in Medical Billing. LinkedIn. December 8, 2022. https://www.linkedin.com/pulse/top-10-causes-denials-medical-billing-trucare-billing.

7. American College of Healthcare Executives. The Change Healthcare 2020 Revenue Cycle Denials Index.

8. Vogel, Slade, & Goldstein. Medical Coding Fraud. VSG Law. www.vsg-law.com/practice-areas/false-claims-act-healthcare-fraud/coding-fraud/.

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Hospitalist Coding with Integrity to Reduce Under Coding

Mar 11, 2024 10:31:41 AM / by Claimocity Team posted in Blog Post

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Claimocity Claims

Hospitalist Coding with Integrity to Reduce Under Coding

Under-coding results in lost revenue.
Over-coding creates unnecessary long term risks for audits and harsh penalties.

how do you code with accuracy and integrity to maximize revenue and minimize risk?

The answer requires understanding the problem in the first place. Insurance companies have a clear financial incentive to make the coding and claim system as complex and problematic as possible because every under-coded visit, denied claim, unresolved issue, or mistake in the process allows them to pay less than they should. They have protections in place against long-term patterns of over-coding and these deterrents have the added benefit of pushing many doctors to play it over-safe and under-code just to make sure they are not putting themselves at risk.

In 2019, an independent third party survey of physicians found that nearly 40% ranked coding
errors as one of the most important issues and 83% felt that improving their coding tools was
one of their top four focuses for the coming year and a critical component to financial growth. 

Issues with our level coding never seemed like an issue until we switched software and experienced what it was like to have the tools in place to do a better job. We thought our financials would go down because it was common knowledge that several doctors in the practice consistently over-coded visits but the reality was that so many of the physicians were unintentionally coding below optimal levels, or since we often cover for each other, mistakenly coding initials as follow ups, that we actually increased net revenue by 8%.

Dr. Steven Silverstein, MD

Solutions for Accurate Hospital Coding

But while there is a clear understanding of the need for better coding and a clear sense of the problem, what are the solutions?

Here at Claimocity, we know that Hospitalists depend on coding accuracy not only for financial viability but from a practical standpoint of progression from initial visit to a series of follow-ups to eventual discharge. Mistakes int he process make it difficult to ensure that a patient is getting the optimal care pattern, especially when doctors are covering for each other and you have to pick up where another Hospitalist left off using nothing but the medical records on file.

Three years before the 2019 study emphasizing the point about the need for better coding, we were developing the very tools that everyone now recognizes as vital to short and long term success.  Our software is a world-class blend of smart technology and billing expertise, and our founders and support staff are global billing experts with decades of experience in the medical industry who specialize in hospital coding.

Our billing experience and expertise makes us uniquely
qualified to analyze level coding for accuracy and integrity.

And when you combine this hands-on professional insight with the most robust data processing, machine learning algorithms, historical pattern analysis, and advanced statistical modeling in the industry, you get coding tools that take all the guesswork out of the process.

We’ve taken the mystery out of the process, and not only help Hospitalists code with accuracy and integrity in a way that maximizes coding revenue and minimizes risk.

Claimocity uses a proprietary smart software level coding optimizer that analyzes the codes entered
at the point of care, performs an initial error analysis within any available pattern data for context before
evaluating the integrity and accuracy of the level coding against huge volumes of historical data.

Not only does it catch the clear outliers on either end of the spectrum and immediately offer notification insights and alternatives, but it generates an ideal set of matches within the parameters of the visit and offers subtle improvement suggestions that offer revenue capitalization without compromising the integrity of the diagnosis or moving outside of the lowest levels of risk.  

Ahead of the curve in so many ways, this tool sets the bar for what is possible and addresses the concerns over coding errors and allows you to ensure that your diagnosis codes are submitted properly with accuracy and confidence.

Our customers love this feature and have reported over a 90% increase in feelings of comfort and understanding in the coding process since they started using our software.

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Use this little footer to reinforce your message about who you are and why people love working with you. And since this is a global module, you only have to edit it once to make the changes across every page it appears on.

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    yourname@company.com
    11035 Lavender Hill Dr. Ste 160-223
    Las Vegas, NV 89135
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