The pediatric billing and coding process is one of the most important, if underappreciated, aspects of the healthcare system. This procedure ensures that healthcare providers receive payment for the services they provide. However, the medical billing for pediatric practices requires a high level of accuracy to ensure that claims are issued and payments are processed quickly. Errors or outdated information can cause major issues in pediatric practice.
For example, failing to enter correct patient demographic information or failing to check and verify patient eligibility can result in costly denied claims. Any changes to patient information must be carefully reviewed and entered, all transmissions must be confirmed, payments must be posted, and accounts receivable must be worked on time.
Since all of this must be done in addition to dealing with patient calls and other day-to-day demands in a busy pediatric office, taking the time to implement the best pediatric coding and billing practices from the start can greatly reduce the risk of confusion or error. Here are some pediatric billing and coding best practices to help your practice create the most efficient system possible and maximize revenue potential:
Before the Visit:
The front desk will oversee verifying eligibility, obtaining necessary authorizations, and collecting co-pays and co-insurance in advance of the visit.
- Check Eligibility Proactively
Checking eligibility allows you to determine the patient’s coverage status prior to the scheduled visit and provides you with the data you need to be proactive about collections. Use your EHR’s electronic eligibility feature at least two days before the visit to capture any patient insurance information that may need to be updated. Keep a current and legible copy of the patient’s insurance card on file for reference, and check to see if there have been any updates prior to the appointment. This helps to avoid delays and denials while also increasing clean claim metrics.
- Review Patient Responsibility
You must ensure that authorizations and referrals are approved, entered into the system, and associated with the appropriate visit. A denial will occur if they are not linked. Furthermore, at every visit, you should ask patients if their policy or coverage has changed. Check for primary, secondary, and tertiary insurance, and inquire about benefit coordination (COB). Keep in mind that Medicaid is always the last resort payer and should not be used as your primary insurance.
During & After the Visit:
A careful check on the pediatric billing and coding operations doesn’t stop once a patient has entered the practice. Instead, it demands the implementation of more comprehensive medical billing for pediatric practices during and after the patient visit. It includes:
- Use Charge Rules:
When bundling commonly used code sets, use charge rules to avoid National Correct Coding Initiative (CCI) edits. Look for covered diagnosis codes by the procedure and common CPT codes that necessitate pre-authorization.
Remember that the goal is to get the pediatric claim paid in full on the first pass. Set a rule to remind pediatric billers to send medical records upon initial submission if a specific payer or CPT code always requires them. When possible, send records electronically to expedite the adjudication process.
- Enter Charges Within Two Days Of The Visit Date
You can avoid both delayed revenue and timely filing denials by entering charges on time. Before a claim can be adjudicated, it must go through several stages. They must be submitted, accepted by the clearinghouse, and the payer, and then entered into the adjudication process.
- Verify Status Reports
Review clearinghouse status reports daily to reconcile claim batches. If a claim is not included in the payer status report, it must be reviewed for missing or incorrect information and resubmitted. Daily claim batch reconciliation is a critical — but often overlooked — component of the pediatric billing workflow.
- Convert your EHR to the Single Source of Truth
Any rejections that have been corrected in the clearinghouse should be reflected in the EHR. This means that any changes made at the clearinghouse level should be updated in the system. This strategy is critical for A/R management and denial management.
How Can 24/7 Medical Billing Services Assist You?
Changing payer fee schedules, government regulations, a lack of training and resources, and high-deductible health plans may all be factors causing your pediatric practice to earn less than it should.
Maintaining financial health in a complex regulatory healthcare environment is no easy task. It is necessary to understand how to get paid for your services, from dealing with claim denials and improving denial management and underpayments to following up on outstanding payments.
In addition to the medical billing for pediatric practices listed above, practices must keep payer fee schedules up to date, file secondary insurance claims, and ensure correct coding to avoid undercharging.
You can also collaborate with revenue cycle management experts of 24/7 Medical Billing Services to increase your pediatric practice profitability. Book your free consultation right today by calling +1 888-502-0537.
Read more: Most Common Pediatric Billing Issues