Maximizing Revenue and Protecting It From Recoupment – Top Strategies

Maximizing Revenue and Protecting It From Recoupment – Three Top Strategies

Revenue cycle optimization is essential for health care providers and organizations to enhance financial performance and boost the bottom line.  While there are many important components to a revenue cycle, the integrity of the revenue is entirely dependent on the underlying services, documentation, and billing being done compliantly.  Health care providers know well that the good feelings accompanying a strong bottom line quickly dissipate and turn to stress, anxiety, and dread when they receive audit findings demanding repayment of those funds.  Fortunately, there are strategies available to providers and organizations to simultaneously maximize revenue and protect it from recoupment.

Every step of the revenue cycle, from patient registration to claim submission and payment collection impacts the payment of claims.  Each of these steps is important and can be improved through refining processes, strategic planning, and workflow optimization.  While improving these steps helps improve revenue, the accuracy and completeness of medical record documentation determines the ability to retain payments on audit.  As a result, internal and external medical documentation and coding compliance audits are crucial. These audits help pinpoint errors, identify medical record documentation deficiencies, prevent recovery on audit, recover lost revenue, and achieve long-term sustainability and growth for the organization – not to mention, giving you peace of mind.

The following are some common issues that result in recoupment on audit and/lost revenue, and that providers and organizations can identify and correct through auditing and monitoring.

1.Insufficient or Inconsistent Medical Record Documentation: Insufficient and inconsistent documentation occurs when a health care professional’s medical records lack the adequate and necessary components to support the claims billed to health care payers. Common errors made by providers include:

  • copying, pasting, and cloning information from one medical record to another;
  • proper authentication of medical records, record entries, and medical orders, such as provider signature and timestamp, attending attestation, attestation supporting “incident-to” billing, and timely completion;
  • missing or incomplete procedure notes; and
  • documentation that fails to include pertinent information, such as the reason for the encounter, medical necessity, history and physical exam, and treatment plan.

According to the U. S. Department of Health and Human Services (HHS) Comprehensive Error Rate Testing (CERT), insufficient documentation was responsible for 17.3% of all improper payments for office-based visits and 74.6% of all improper payments for minor procedures under Medicare Part B services. (2023 Medicare Fee-For-Service Supplemental Improper Payment Data, 2023)

2. Coding and Billing Errors: Inaccurate coding can lead to compliance issues, claim denials, overpayment, and false claims submission by the health care organization. Certified medical coders and auditors will ensure that the correct Current Procedural Terminology (CPT®) code is selected, proper utilization of modifiers, assigning ICD-10-CM codes that align with clinical documentation, place of service, and payer-specific policies. Failure to remain compliant will result in unbundling of procedures, upcoding, improper usage of modifiers like 25 and 59, and misinterpretation of coding guidelines. Incorrect coding results in nearly 71% of all improper payments for office-based visits and 3% for all minor procedures under Medicare Part B services. (2023 Medicare Fee-For-Service Supplemental Improper Payment Data, 2023)

3. Third-Party Billing Companies: Many health care organizations partner with third-party billing companies to handle the submission of medical claims to insurance companies and manage the revenue cycle. Health care organizations, however, are ultimately responsible for managing compliance risks associated with external billing departments and ensuring that billing practices align with industry standards and regulations. Additionally, the OIG underscores the importance of compliance program guidance for third-party medical billing companies in combating health care fraud and abuse. Standard procedures that health care organizations should emphasize include:

  • auditing the claim form for CMS-1500 to ensure that the billing company submits clean claims;
  • ensuring proper CPT, ICD-10-CM, HCPCS, modifiers, and place of service;
  • minimizing unnecessary write-offs by implementing a robust appeals process;
  • maintaining compliance by staying up-to-date on Centers for Medicare and Medicaid Services (CMS), state, and commercial payer guidelines; and
  • tracking claims coming in and out of the billing company through advanced reports.

Tackling these issues through internal and external auditing of medical records and related claims will go a long way in protecting your revenue on audit, identifying areas for enhanced billing, and giving you peace of mind.

Schedule an audit with Garfunkel Health Advisors (GHA) today to hopefully avoid a substantial recoupment demand.

About Garfunkel Health Advisors (GHA): We are a team of dedicated subject matter experts focused on comprehensive industry expertise spanning administrative, medical coding, auditing, clinical documentation improvement (CDI), revenue cycle management (RCM), workflow development, and documentation and coding compliance. With GHA, you can minimize compliance risks, improve operational efficiency, and achieve financial integrity.

Garfunkel Health Advisors