Medical billing and coding is a complex process with intricate patterns and numerous steps. Financial stability and patient satisfaction are directly concerned with the success ratio of medical billing processes in any healthcare facility. Orthodox ways of medical billing and coding are error-prone because of their manual nature and less use of technological innovations.
Even after taking necessary measures according to the present era’s demands, there are still many challenges in medical billing. If you want to run a medical practice and earn good revenue in return for patient care, then it is necessary to understand the top struggles in medical billing and coding and find solutions for such problems.
In this article, we will learn what is medical coding and billing process? We will also discuss common challenges in medical billing and coding along with potential solutions to overcome these roadblocks.
Understanding of Medical Billing and Coding
Medical coding and billing is a process of generating medical bills and submitting claims to insurance companies to get reimbursement. Reimbursement is demanded in return for patient care services provided to the patients in the hospital facility.
Assigning medical codes for the rendered services in the medical bills is called medical coding, while medical billing refers to submitting claims and follow-ups to ensure that healthcare providers are properly reimbursed for their services. These two processes are done together, but they are different from each other. Medical billing and coding are the backbone of the healthcare revenue cycle. Below are a few common challenges providers face while billing and coding:
1. Incorrect Patient Information
When patients present in the hospital, their information is checked and verified as first priority. Initial scrutiny ensures that their insurance companies cover their medical treatment and they are eligible to get immediate patient care. Their personal and demographic information is noted, but it is quite common to write patient information incorrectly. Errors like misspelled names, outdated insurance information, and inaccurate personal details can lead to claim rejection and revenue loss. These mistakes occur because many patients are being handled at one time.
Solution
It is recommended to double check the data to ensure that patients’ information is correct. Use of electronic health records (EHRs) for data entry is helpful to avoid duplication and information verification. Providers also need to contact the patients before their visit to verify their details and insurance coverage.
2. Coding Errors
Coding is the cornerstone of the medical billing process, as the amount of reimbursement depends on specific codes used in the medical codes. However, among medical billing challenges, coding errors are at the top of the list because of less-skilled workers and coding updates. The use of incorrect code or modifiers leads to abrupt claim denial and rejection.
Solution
Healthcare facilities need to train their staff to keep them updated with new billing and coding guidelines. Well-skilled and expert staff keep complete knowledge of all codes like CPT codes, ICD-10 codes, HCPCS codes. Providers can also use technology to detect coding errors before submitting the claims. Audits also have great significance in identifying trends in errors and suggesting useful actions.
3. Claim Denial and Rejection
Finances and revenue cycle are affected by the number of denied/rejected claims. It has been reported that claim denial is a common challenge in many healthcare facilities. From small errors like incorrect information to big mistakes like lack of documentation, it directly leads to claim denial and revenue leak.
Solution
Errors and mistakes in medical bills should be detected before submitting the claims. This can be achieved by introducing billing softwares which can check errors before submission. Previous denied claims should be analyzed to determine the common pattern leading to errors. Such measures are helpful to find errors and rectify them.
4. Lack of Documentation
Documentation is necessary from patient presentation to the final outcome of the management plan. Lack of documentation makes it difficult for providers to justify the medical necessity and the indications for rendered services. Maintaining documentation strengthens the stance of providers and their chances of claim acceptance. Documentation is considered among the top struggles in medical billing and coding. Only billing experts can maintain documentation for claim submission and future use.
Solution
Train and educate providers on how to document each medical service. Healthcare facilities should introduce templates to record information of a patient’s history, examination, findings and management plan. Enhance collaboration between healthcare providers and billers to maintain documentation records according to payers guidelines. Use EHRs to record patients information for future use.
5. Changing Regulatory Requirements
The Healthcare industry is highly evolving and new policies are introduced for making billing and coding systems better and useful for patients, providers and billers. But it is also a challenge for providers and billers to follow all billing guidelines. Non-alignment with billing policies by Medicare, Medicaid and HIPAA can result in claim rejection.
Solution
It is the duty of healthcare facilities to arrange seminars, webinars and workshops to keep providers and billers updated with new regulatory changes. Healthcare facilities can also hire third party service providers for billing tasks. Such service providers are expert in medical billing and comply with all billing guidelines.
6. Lack of Staff Training
Having less-skilled staff is considered among common challenges in medical billing and coding. Untrained staff is prone to errors in medical coding, claim submission and appeals for denied claims. This can lead to financial instability and compliance risks.
Solutions
It is recommended that certified staff only be hired for medical billing. Effective billing is the basis of the successful running of medical practice and enhanced patient care. Periodic performance evaluation of each staff member is necessary to ensure that they are well-skilled and continuously learning new billing guidelines.
7. Delayed Payment from Patients
Apart from payers, patients sometimes bear a good sum of money to pay for getting medical services. Delays in payment by patients to healthcare facilities are commonly reported. Patients struggle to pay bills because of inefficient payment methods or lack of communication.
Solution
Inform the patients about estimated medical bills during their visits and maintain good communication to clear their queries related to payment. Such measures can maximize revenue collection. Healthcare facilities also need to form a portal mentioning all payment details and effective methods. Automated reminders to patients can also be helpful in this regard.
8. Appeal for Denied Claims
This is very important to manage denied claims as such claims contain a great percentage of revenue. Many medical billers and coders fail to follow-up denied claims and clear objections raised by payers.
Solution
There should be an appeal team expert in managing denied claims. Providers can also hire third parties who have proven track records in managing claims. Introducing standardized templates for common mistakes and errors is also helpful to speed up the process.
9. Submitting Multiple Claims
Some providers need to submit many claims at once which can be frustrating and error-prone. For example, nephrologists have to submit multiple dialysis claims one by one. This affects the clinical workflow and patient care as submitting hundreds of such claims need time and resources.
Solution
Insurance companies should accept mass claims in a single submission to provide some ease to the providers. Providers can also use technological innovations like billing software to automatically submit claims for the same medical service.
10. Billing Telehealth Services
Telehealth has emerged in COVID pandemic as the main pillar in providing healthcare services. It has come with new billing complexities and new challenges. Each payer has specific billing guidelines for Telehealth services which is difficult for medical billers to comply with.
Solution
Provide training and education to medical billers about the Telehealth billing guidelines. Confirm patient Telehealth insurance coverage before starting patient care.
Conclusion for the Challenges in Medical Billing
Medical billing and coding is a daunting process with numerous challenges. Healthcare facilities should take specific measures to mitigate such hurdles. Missing information, new regulatory policies, denied claims, untrained staff, and lack of documentation are common medical billing challenges. Submitting multiple claims and complex telehealth guidelines can also create problems in effective billing. Using billing software, hiring professional billers, and continuous learning can be game changers in medical billing and coding. Also read our blogs to know more about coding and billing basics.
Challenges in Medical Billing FAQs
1. What is the biggest challenge in medical billing?
Managing claim denials and rejections is considered the biggest billing challenge. Missing information, incorrect use of codes, lack of documentation and failure to follow billing guidelines are the reasons behind claim rejection.
2. Why is medical billing so complicated?
Medical billing involves multiple steps and many regulatory obligations which make it error prone and complex. Use of complex codes, complying with updated payer policies and following billing guidelines make the billing process so complicated.
3. What is the basic medical billing workflow?
Medical billing workflow involves various steps, which are described below:
- Patient Registration
- Insurance verification
- Coding service
- Claim submission
- Managing denied claims
- Receiving patient payment
All steps are necessary to ensure timely reimbursement for the rendered medical services.
4. What is the hardest thing about medical billing and coding?
Staying updated with coding guidelines, ever-changing regulatory policies, and coding standards like CPT and ICD-10 is the hardest thing. It is necessary for billers to follow all updates to get reimbursed on time.
