The Centers for Medicare & Medicaid Services (CMS) subsidizes healthcare in specified rural areas by paying encounter rates for services performed as well as the overhead necessary to provide them.
It is not, however, free money. Providers of rural health clinics (RHCs) must keep track of services delivered and provide yearly totals. They must also submit and process claims for patients and services covered by the rural health initiative differently than those submitted as fee-for-service engagements.
These distinctions might pose difficulties for rural clinics, which may not have the same level of Rural Providers & Suppliers billing and coding knowledge as suburban and urban practitioners. When accounts receivable (A/R) days exceed three weeks, physicians are more likely to use personal finances to meet payroll, putting further strain on rural operations.
Understanding coding differences, submitting clear claims the first time, and revising claims as near to rejection as feasible can all help rural practices get back to their fundamental goal of providing the best possible care to patients.
The correct solution after identifying the unique challenges attached to the rural providers related to the suppliers billing will help them increase their operations’ efficiency. Let’s have a look at the unique challenges and solutions attached to their practice RHC billing:
Challenge #1: Claim Errors
Solution: Enhance UB-04 Edits
If you submit an electronic 1500 form for fee-for-service, the insurer will most likely notify you right away if there are any obvious issues in the claim, such as a name mismatch. You’ll have to wait for more subtle denials, such as the erroneous CPT code or an invalid procedure for someone of a certain gender, but the insurer at least looks at the claim.
Submit a UB-04 claim to Medicare and be prepared to wait 21 days for a decision. In this setting, any errors, no matter how obvious, are exacerbated by the three-week interval before a denial. Rural health providers require claims software that enables front-end edits before the claim is submitted to Medicare.
Though claims software cannot recommend specific CPT codes for individual operations; nevertheless, astute software providers can analyze CPT and revenue codes, for example, and highlight any variations. But medically implausible volumes of supplies or treatments, as well as CPT codes that should not be billed together, should be flagged by software.
Challenge #2: Increasing Denials
Solution: Get Early Denial Alerts
Many clearinghouses use a similar process, issuing periodic reports that provide a picture of claims at that point in time, comparable to how Medicare waits 21 days to notify rural health clinics of denials. Billing personnel must sift through the reports for anomalies and delve deeper into rejections. Days may elapse between the time a report is created and the time billers have to interact with the report – days during which the practice is not paid.
Clinics want claims software that automatically generates denials as soon as they are discovered and as part of typical procedures. Faster notification of claims that are likely to be denied gives billers more time to investigate each anomalous claim and take proactive efforts to submit a claim that will be appropriately reimbursed.
Challenge #3: EOBs Related Issues
Solution: Leverage Faster EOB Determinations
EOB statements, like denials, are frequently issued on a regular basis, with RHCs getting them in the form of mail or billing staff having the option of downloading them from the insurer. To understand how EOBs affect revenue, billers must examine each form to ensure revenue is correctly posted and to establish whether patients owe extra money because a visit or operation falls under their deductible.
Clinics require software that analyses each EOB, matching claims and instantly reporting any irregularities (such as contractual adjustments and patient responsibility) to billing staff. Rather than going through each EOB, billers might look through the returned EOB list to identify why the claim was not paid in full and the next steps. Rural health clinics can reduce the time between patient visits and payment by immediately returning claims that require additional work.
Challenge #4: Low Reimbursements
Solution: Outsourcing Rural Providers & Suppliers Billing to 24/7 Medical Billing Services
Rural health clinics frequently keep communities together by offering crucial services that keep people from going longer distances to receive healthcare. However, finding and educating billers and coders who understand the complexity and nuances of both the UB-04 and 1500 claim forms can be difficult. Furthermore, missed time submitting, monitoring, and reconciling claims delays A/R days, which can leave RHCs cash-strapped.
Rural healthcare providers should look into outsourcing to 24/7 Medical Billing Services, having a team of experts to process UB-04 and 1500 claims, allowing UB-04 editing, returning denial alerts as part of routine workflows, and reconciling every EOB to claims expectations. So, what are you waiting for? Contact their revenue cycle management team right now.