Advanced Revenue Cycle Analytics: An Overview
Accurate medical coding is essential to getting paid, regardless of the method used by the physician for capturing the charge data (e.g., paper encounter forms, electronic medical record). Strictly entering the correct codes for a procedure or diagnosis is never enough. After a physician finishes documenting a patient encounter, the claim is sent to the billing office for a final review. When an encounter is in the hands of billers and coders, the complex rules of medical necessity, correct coding and carrier-specific insurance rules come into play. If a claim is denied, it is most often due to data-entry errors, gender-specific/age-specific errors, registration errors, missing modifiers, or a lack of medical necessity. Reprocessing denied claims accrues additional costs and takes away from the practice’s bottom line.
It is more difficult to process claims today than ever before. Stricter payer rules, complicated incentive programs (e.g., e-Prescribing, PQRS, EHR Stimulus), and emerging technologies such as electronic medical records (EMRs) and electronic health records (EHRs) create a work environment where physicians see fewer patients for less money. Physicians are faced with the dilemmas of meeting government requirements to comply with incentive programs that will one day turn mandatory, submitting claims correctly in an increasingly audit-driven payer environment, and learning to navigate difficult and sometimes tedious EMR applications. Time is money, and there are a lot of outside forces slowing down a physician’s daily workflow.
How White Plume Can Help
Many code-scrubbing engines in the market provide basic data review that checks for obvious errors, such as invalid codes, published CMS rules, and some measure of modifier review. However, AccelaSMART goes beyond traditional code-scrubbing engines and provides a way for medical practices to custom-fit our editing software to their unique billing situations. AccelaSMART reviews claims based on:
- Demographic Data – Compares demographic data in the appointment (such as patient age, gender and insurance) to the procedures and diagnoses selected.
- Custom or User-defined Edits – Provides users with the ability to create their own carrier, physician, and speciality specific, code-scrubbing rules that cover both simple and complex coding scenarios.
- Suppression of Edits – Allows users to suppress any standard edits that do not apply to their particular billing situation which helps users avoid wading through irrelevant data.
- Batched Encounters – Enables users to process large quantities of encounters before they are posted to the PM system. Rather than reviewing claims one at a time, both good and bad, AccelaSMART only stops for review the claims that are flagged with errors. Corrections are made directly to the encounter where the error is found without requiring users to toggle back and forth between an error report and the claim.
- Evaluation and Management Level – Evaluates the level of Evaluation and Management (E/M) codes to see if the service is considered too low or too high based on diagnosis selected.
Ultimately, AccelaSMART consolidates coding data and allows billers to process claims more quickly and accurately while dramatically increasing the likelihood that physicians will get paid for a claim the first time it is submitted to an insurance company.