The Balancing Act of Medical Coding

Medical coding is part algorithm and part interpretation, because no two patients are the same, and each surgery is different even if the outcome is the same. Specialists need to code accurately, to avoid claims rejections and audit scrutiny, which often results in not billing for services that were indeed provided, thus directly affecting revenue. Conversely, excessive use of codes, a practice known as “code farming,” can trigger claims rejections and, even worse, audits. It’s crucial to code accurately for the services rendered without crossing into the territory of overcoding, which can attract unwanted attention.

The consequences of being flagged for an audit are significant. During the audit process, payments from schemes are withheld, creating cash flow interruptions. If an audit determines overbilling occurred, not only are those funds recovered, but the practice also lands on a “watchlist.” Being under continuous scrutiny means that even minor errors can be penalised harshly, impacting long-term financial stability, and creating unnecessary stress for the specialist.

It is also important to realise that medical aids will never actively assist you to code correctly, and they will certainly not thank you for under coding. On the contrary, they will actively pick up on incorrect coding when they perceive that they may be being overcharged for services rendered. The unfortunate truth is that it is an asymmetric relationship where medical schemes have to manage funds to get the most service for the least amount, while specialists are incentivised to bill optimally in order to optimise their revenue.

Delays in claims submissions can result in denied claims. Claims for services rendered need to be submitted within four months of the service date or they become stale and will not be reimbursed. Four months may seem like a long time, but when things get busy and a specialist doesn’t have a good system and the right support, it is possible to miss this deadline. It’s essential to have a system that ensures timely and accurate claim submission to avoid the lost revenue from stale claims.

In addition, providing patients with clear and upfront information about the potential costs and shortfalls is crucial. This transparency helps in avoiding unhappy patients due to financial surprises, which is important not only from a consumer protection standpoint but also to prevent potential complaints to the Health Professions Council of South Africa (HPCSA).

How Revenue is Lost

Revenue loss often accumulates insidiously through small inefficiencies and oversights:

• Inaccurate coding for services rendered (underbilling)
• Use of billing systems using incorrect tariffs (underbilling that occurs due to services being billed below their actual value)
• Having the incorrect practice billing policy (i.e. which schemes to contract with, if any)
• Failure to capture or update patient information correctly, leading to claim rejections.
• Poor follow-up on partially reimbursed, or rejected claims, letting potential recoveries slip away.
• Allowing claims to go stale.

Optimising Earnings with an Expert
Billing Company

The Specialist Billing Collective (TSBC) offers comprehensive solutions to overcome these billing challenges. Here’s how partnering with TSBC can safeguard and enhance your billing processes and your practice’s revenue:

Expert Coding and Claims Management:

Our staff are trained experts in coding standards and ensure that your claims are neither under nor over-coded. This precision prevents audits and secures your revenue.

Quality Practice Management Systems:

By utilising the best practice management system on the market, TSBC simplifies and accelerates the billing process, from service to payment, while providing detailed analytics to pinpoint financial improvement opportunities.

Optimal Practice Billing Policy Setup:

TSBC will analyse where you work, your patient base, and the type of work you do to ensure the optimal mix of which schemes (if any) to enter into contractual payment arrangements with.

Proactive Revenue Recovery:

We actively manage every step of the claims process, rigorously following up on any partial payments and rejections to maximise your revenue recovery.

Personalised Patient Communication Strategies:

We help you communicate clear financial expectations with your patients, enhancing the collections rate and reducing administrative costs. Our approach ensures patients are fully informed about their financial obligations, which helps maintain trust and satisfaction, crucial elements in patient relations and practice reputation.

Conclusion

Effective billing practices are critical for the financial health of any medical specialist’s practice. Understanding the nuances of medical coding and the importance of billing management will transform the financial dynamics of your practice. With TSBC, you will secure your revenue, minimise administrative burdens, and focus more on patient care. Let us help you navigate the complexities of medical billing and optimise your practice’s financial performance.

In our following blog posts, we will unpack the concepts discussed above in greater detail with practical case studies from specialists we have assisted in the past.