Group practices—whether multi-specialty or single-specialty—are on the rise, and with that growth comes a need for smarter, scalable revenue cycle strategies.

Group practice billing isn’t just about managing a higher claim volume; it’s about aligning clinical, administrative, and financial operations across multiple providers and locations. In this article, we explore what’s working in 2025, where the pitfalls are, and how group practices can position themselves for stronger financial outcomes.

Why Group Practices Need Specialized Billing Strategies

Group medical practices face unique challenges that differ from solo providers or hospital systems. These include:

• Multi-provider coordination
• Centralized billing and reporting
• Diverse specialty-specific coding
• Complex payer contracts across sites
• Credentialing at scale

A one-size-fits-all billing approach simply doesn’t cut it anymore. Success in group practice billing now relies on customized RCM strategies, dedicated account management, and real-time performance analytics.

10 Billing Errors Costing Your Multi-Specialty Practice Thousands Every Month — And How to Fix Them Fast?

What’s Working in Group Practice Billing in 2025

1. Centralized Billing Infrastructure

Centralization is key. Group practices that consolidate their billing operations across all locations see better consistency in data, cleaner claims, and fewer compliance issues. A centralized approach also makes it easier to:

• Standardize charge capture processes
• Unify reporting dashboards
• Monitor provider-specific performance

2. Data-Driven Revenue Cycle Management (RCM)

In 2025, leading group practices are using predictive analytics and real-time reporting to make informed decisions. Whether it’s spotting coding trends or identifying payer delays, data visibility is driving outcomes—not just operations.

3. Dedicated Billing Teams for Multi-Site Practices

Working with a billing partner that assigns Dedicated Account Managers ensures every location gets the attention it needs. These teams know your workflows, your specialties, and your KPIs—and they don’t just manage billing, they improve it.

4. Credentialing and Payer Management at Scale

Group practices can’t afford to let payer enrollment delays stall growth. Efficient credentialing services and proactive payer contract management are essential to keeping new providers billable and revenue flowing.

5. Flexible Pricing Models

2025 has shown us that RCM partnerships must be adaptive. Whether your group practice is expanding, merging, or changing specialties, your billing solution should offer flexible pricing models that scale with your needs—not lock you in.

Key Outcomes Group Practices Can Expect with the Right Billing Partner

• Reduction in claim rejections and denials
• Faster reimbursement cycles
• Better cash flow predictability
• Improved provider satisfaction
• Actionable insights for operational planning

At MBC, our tailored approach to group practice billing helps clients go beyond basic collections. We focus on outcomes that improve clinical operations and financial stability across the board.

Frequently Asked Questions

1. How do I streamline billing for a group medical practice?

To set up group practice billing, you need a centralized billing system, provider credentialing across payers, and integrated workflows across locations and specialties. Outsourcing to an experienced RCM partner like MBC ensures a smoother, scalable setup.

2. What are the biggest billing challenges for group practices?

Top challenges in 2025 include:

• Managing multi-provider credentialing
• Claim denials due to inconsistent charge capture
• Lack of centralized data reporting
• Delays in payer reimbursements across sites

3. Can a group practice use one NPI number for all providers?

No. Each provider must have their own individual NPI (Type 1), while the group practice has a group NPI (Type 2). Billing must align with both for proper payer identification and compliance.

4. What billing software is best for group practices?

There’s no one-size-fits-all. The best software depends on your specialties, size, and workflow. Practices often integrate EHRs with billing systems or partner with an RCM vendor who can centralize data and work across platforms like Athenahealth, eClinicalWorks, or NextGen.

5. Is it better to outsource billing for a group practice?

For most growing practices, yes. Outsourcing to a billing partner like MBC allows for:

• Scalable operations
• Expertise in multi-specialty coding
• Better denial management
• Lower overhead costs compared to in-house billing teams

6. How much does group practice billing cost?

Pricing varies based on volume, specialty, services provided, and complexity. At MBC, we offer flexible pricing models tailored to your practice’s needs and growth stage, rather than flat percentages.

7. How do billing errors impact a group practice?

Billing errors—especially in multi-provider environments—can lead to denials, payment delays, compliance risks, and even audits. That’s why consistent coding, centralized QA, and dedicated billing oversight are critical for group practices.

The post Group Practice Billing: What Works in 2025 appeared first on Medical Billing and RCM Blogs.

“The jury is out, but COVID is probably going to exacerbate larger systems buying up independent practices because a lot of folks just aren’t going to be able to weather the storm long enough,” says Ryan Schmid, MBA, president, and CEO of Vera Whole Health.

It is, however, important to note that by independent practices Schmid is talking about the traditional physician practice built on fee-for-service.

“We have not seen any kind of financial disruption because our contracts are value-based, which means that literally overnight, we were able to shift to mostly virtual care,” Schmid explains. “And we’ve been able to continue to perform against those requirements because we’ve been able to keep engaging members.”

The company actually gained more capacity to do the activities it specializes in, like care coordination, closing care gaps and member outreach.

“It [COVID-19] shone a light on the differences between the traditional, hospital-owned, fee-for-service primary care and advanced primary care with respect to one’s ability to actually provide comprehensive services,” Schmid states.

Adding a service line may be too heavy of an investment for most practices though, especially for services that have been historically under-reimbursed by payers, like behavioral health and telehealth.

Value-based contracts like those used by Vera Whole Health, however, can help practices integrate a new service line and start generating value from it immediately.

That is because of the economics of the model, Schmid explains.

At-risk payment models, like capitation, give providers the flexibility to deliver the care their patients need without being tied to the actual volume of services rendered.

A study conducted by Harvard Medical School and American Board of Family Medicine early during the pandemic found that primary care practices are on track to lose a significant amount of revenue (an average of $325,000 per typical five-person practice) from fee-for-service payments, even under the relatively optimistic assumption that practices quickly pivoted to virtual care to recoup revenue from lost in-person visits.

Practices are now experiencing historic income reductions because of COVID-19, but for those who are still unsure of the effects alternative payment models will have on their practice, there is another way.

Accountable care organizations, independent practice associations, and other group-based models can also help practices with the back-office investment needed for alternative payment models. Fortunately, many of these types of collaborations already exist in most markets.

“In some markets, direct primary care is more prevalent than others so if they happen to be in a market where they can essentially sell memberships to individual consumers, look for ways to do that,” Schmid advises.

But payers are interested in keeping independent practices independent, Schmid says, so if practices can pull together, they can “create some bargaining power to go to the payers to get better value-based contracts.”

Practices jumping into value-based contracts should consider how patients will be assigned to them under the arrangement. Schmid recommends that practices think of how they will control downstream spend and influence patient behavior to ensure optimal care delivery whenever possible.

In addition, practices need a strategy for documenting care delivery to ensure potential gaps in care are identified and to prove providers delivered the most appropriate care for that patient.

About Medical Billers and Coders

We are catering to more than 40 specialties, Medical Billers and Coders (MBC) is proficient in handling services that range from revenue cycle management to ICD-10 testing solutions. The main goal of our organization is to assist physicians in looking for billers and coders.

The post How to keep your independent practice strong during COVID-19? appeared first on Medical Billing and RCM Blogs.

These states are:

• Delaware
• District of Columbia
• Maryland
• New Jersey
• North Carolina
• Pennsylvania
• South Carolina
• Virginia
• West Virginia

Medicare may provide cover for ambulance services, including air ambulance services if the ambulance service is furnished to a beneficiary whose medical condition is such that other modes of transportation are contraindicated. The beneficiary’s condition must require both the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary.

Repetitive Ambulance Service

This extension started last year December and ends on December 1, 2020. A repetitive ambulance service is defined as medically necessary ambulance transportation that is furnished in 3 or more round trips during a 10-day period or at least 1 round trip per week for at least 3 weeks.[2] Repetitive ambulance services are often needed by beneficiaries receiving dialysis or cancer treatment.

Medicare may cover repetitive, scheduled non-emergent transportation by ambulance if the,

• Medical necessity requirements described previously are met; and
• The ambulance provider/supplier, before furnishing the service to the beneficiary, obtains a written order from the beneficiary’s attending physician certifying that the medical necessity requirements are met (see 42 CFR 410.40 (d)(1) and (2)).

Assistance with Alternative Transportation Resources

According to CMS, Medicare beneficiaries who do not qualify for coverage of repetitive, scheduled non-emergent ambulance transportation under the Medicare benefit are encouraged to check into other services:

• Medicare beneficiaries who receive a non-affirmed prior authorization decision letter can call Fed Pro Services, LLC at 1-888-855-0542 for assistance until July 17, 2020, when this Medicare service ends. TTY users should call 1-855-200-0763. Customer service representatives will discuss beneficiaries’ transportation needs and direct them to the most appropriate transportation resources in their area.
• Medicare beneficiaries can ask other programs that they may be a part of, like Medicaid or Programs of All-inclusive Care for the Elderly (PACE) if they qualify for their help with transportation coverage.
• Medicare beneficiaries can also contact Eldercare at 1-800-677-1116 or their local State Health Insurance Assistance Program to ask about other state and local services that can help.

COVID-19 Pandemic Update

The testing of the Medicare Prior Authorization Model for Repetitive, Scheduled Non‑Emergent Ambulance Transport under section 1115A of the Social Security Act (the Act) is being extended in the current model states of Delaware, the District of Columbia, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, and West Virginia for one additional year while CMS continues to work towards nationwide expansion under section 1834(l)(16) of the Act. You can see more information about this notice on the Federal Register Gov Website.

The prior authorization process under the extension of the model under 1115A authority will continue to apply in the nine states listed previously for the following codes for Medicare payment:

• A0426: Ambulance service, advanced life support, non-emergency transport, Level 1 (ALS1).
• A0428: Ambulance service, BLS, non-emergency transport.

While prior authorization is not needed for the mileage code, A0425, a prior authorization decision for an A0426 or A0428 code will automatically include the associated mileage code.

About Medical Billers and Coders

We are catering to more than 40 specialties, Medical Billers and Coders (MBC) is proficient in handling services that range from revenue cycle management to ICD-10 testing solutions. The main goal of our organization is to assist physicians looking for billers and coders.

The post Extension of Prior Authorization for Repetitive, Scheduled Non-Emergent Ambulance Transports appeared first on Medical Billing and RCM Blogs.

Practices are often reluctant to collect estimated patient responsibility at the time of service because of confusion over whether they are allowed to do so. Since many patients are now covered by high-deductible health plans, many payers have become more flexible in allowing deductibles and coinsurance to be collected at the time of service.

The payment amount made by the patient will need to be included in the claim when it is submitted to the payer. Payers also require that any overpayment made by the patient be promptly refunded.

Physician offices with the ability to provide an upfront cost estimate to a patient can help eliminate an unexpected bill, which may cause problems for the patient and, ultimately, the practice. Physicians spend years developing relationships with their patients and a surprise bill may destroy that connection in a moment. Primarily because no one likes this kind of surprise and some patients struggle to pay an unanticipated bill.

If you are considering enforcing the time of service payment collections as part of your revenue cycle strategy, which is highly recommended, make certain to look over your payer contracts. You may also want to seek guidance from a healthcare attorney for clarity regarding state laws and whether payments can be collected from patients before claim adjudication.

This depends on how capable your office is when it comes to monitoring your patient accounts. You should also assess how well your practice management software supports your patient collections process. There is also an administrative burden when dealing with overpayments. Unless the patient is nowhere close to satisfying their deductible, it’s likely that you will end up having to issue a refund.

An example in which this may happen, despite the best effort in estimating what they may owe, is when a claim from another provider is processed before your claim. In this case, a deductible may no longer be owed.

It’s also worth mentioning that you should be aware of your patients have an FSA (flexible spending account) or HSA (healthcare spending account) tied to their insurance. This brings us to having a credit card on file. Being able to charge patients immediately after services are rendered is a great way to get paid promptly. It also allows you to get authorization to charge up to a certain amount automatically directly after adjudication.

For patients that have an FSA or HSA tied to their insurance, you may still want to consider using the credit card on file approach as opposed to collecting the estimated amount. This could help you avoid having to issue a refund if the estimate is not accurate. Again, if another provider’s claim hits before yours, this will alter the patient’s remaining deductible.

Some reports show that practices only collect 50% of patient responsibility after patients leave their offices. To further improve your collections rate, consider collecting a percentage of the full estimated amount at the time of service.

Many practices have been successfully estimating patient responsibility for years using a combination of a spreadsheet listing their most commonly used CPT codes and the associated reimbursement rates for their common payers.

This coupled with your current process of eligibility verification, should allow for a fairly accurate estimate of what the patient’s responsibility will be for the visit. You can then have a conversation with them about their payment options.

Estimating a patient’s responsibility is just one piece of the overall patient collection process. It’s vital that your financial policy is clear and up to date. It should reflect what your requirements are regarding payment at the time of service.

Expectations should be set up front before services are rendered to avoid confusion. It is also imperative that your staff is familiar with these policies and is trained to implement them appropriately. To increase the effectiveness of the patient collection process, it should be streamlined with overall medical billing functions.

Medical Billers and Coders (MBC) provides billing services which include estimating the patient responsibility module also. To know more about our medical billing services you can contact us at 888-357-3226/info@medicalbillersandcoders.com

FAQs:

1. Why is it important to collect patient payments at the time of service?

Collecting payments upfront helps eliminate unexpected bills for patients, strengthens relationships, and improves cash flow for the practice.

2. Can practices legally collect estimated patient responsibility before insurance claims are processed?

Yes, many payers now allow practices to collect deductibles and coinsurance at the time of service, but it’s essential to review payer contracts and state laws.

3. How can practices provide accurate cost estimates to patients?

By using a combination of common CPT codes and reimbursement rates, alongside eligibility verification, practices can estimate patient responsibilities more accurately.

4. What should practices do if a patient overpays?

Practices must promptly refund any overpayments made by patients, especially if the deductible changes due to claims processed by other providers.

5. How can practices streamline their patient collection process?

Implementing a clear financial policy, training staff on payment procedures, and using billing services that include estimating patient responsibilities can enhance the collection process.

The post Estimating Patient Out-of-Pocket Responsibility appeared first on Medical Billing and RCM Blogs.

This is the most important of the three key components because the Medical Decision-Making (MDM) reflects the intensity of the cognitive labor performed by the physician. There are four levels of MDM of incrementally increasing complexity Straightforward; Low Complexity; Moderate Complexity; and High Complexity.

Physicians must stratify the MDM into one of the above levels of complexity based on:

When referring to the table, the level of risk is determined by examining three separate dimensions of the encounter:

• Presenting Problems
• Diagnostic Procedures
• Management Options Selected

Tip: The E/M guidelines explicitly state that the highest level of risk present in any one of the above categories determines the overall risk of the encounter. Physicians often underestimate the level of risk as defined by the E/M guidelines.

Decision-Making Point System

A casual review of the official rules for interpreting the key component of Medical Decision-Making shows that the criteria for quantifying physician cognitive labor are quite ambiguous. Medicare discovered that auditors were having a hard time nailing down the level of Medical Decision-Making during the medical review process.

In response to this problem, a more objective Medical Decision-Making Point System was developed by CMS. Although not part of the official E/M guidelines, this MDM Point System was distributed to all Medicare carriers to be used on a “voluntary” basis.  In point of fact, this is the way your Medical Decision-Making will be graded in the event of an audit.

This approach uses a matrix of weighted points to answer most of the questions left open by the official E/M guidelines regarding the MDM.  Instead of vague words like “extensive”, the MDM Point System uses a numeric scale to describe the number and nature of the diagnoses being addressed.  These issues are quantified using “Problem Points”.

Similarly, the extent of the data reviewed is quantified by using “Data Points” which reflect the volume and complexity of the information processed by the physician.  Risk is determined by referring to the identical table of risk used by the official E/M guidelines.

Problem Points

The “nature and number of clinical problems” are quantified into Problem Points by referring to the following table:

The above table is fairly self-explanatory.  An example of a “self-limited or minor” problem may be a common cold or an insect bite.  An “established problem” refers to a diagnosis, which is already known to the examiner, such as hypertension, osteoarthritis or diabetes.

An example of a “new problem with no additional workup planned” may be a new diagnosis of essential hypertension.  Examples of “new problem, with additional workup planned” may include any new clinical issue which requires further investigation such as chest pain, proteinuria, anemia, shortness of breath, etc.

Tip: Problems that are not being addressed specifically by the physician during the encounter may still be counted if they significantly increase the complexity of the cognitive labor required.  For example, consider a patient with diabetes who is being evaluated by a vascular surgeon for a lower extremity revascularization procedure.

It would be appropriate for the surgeon to include diabetes as an “established problem, stable” when calculating the problem points.  This is because the comorbidity of diabetes does significantly influence the risk of the procedure and the complexity of post-operative management.

Tip: Problems are defined relative to the examiner, not the patient.  Even if the problem was previously known to other physicians or to the patient, it is still considered new to you if you are seeing the patient for the first time. This situation arises often in the case on consultations.

Data Points

The “amount and complexity of the data reviewed” are quantified by referring to the following table:

The physician should be aware that no “double-dipping” is allowed.  For example, if you review lab results and order labs during the same visit, you only get one point (not one point for ordering and one point for reviewing).  This same rule applies to image studies or other medical tests such as EKGs or PFTs.

Commonly overlooked points are those garnered for obtaining or reviewing old records.  If you do review old records, you must summarize your findings in the chart.  It is not acceptable to just say, “Old records were reviewed.”

Tip: Notice that points can accumulate quickly if you personally review an image, tracing or specimen.  You can still claim these points, even if the image, tracing or specimen has been reviewed by another physician (as when a radiologist provides an official interpretation for an X-ray).  However, you must include your own interpretation in the chart in order to claim these points.

After calculating the Problem Points and the Data Points and stratifying the level of risk, the overall complexity of MDM is determined by referring to the yet another table:

MDM Points Table

(Two out of three must be present to qualify for a given level of MDM)

Example:

Suppose you see a patient in the office with stable diabetes and sub-optimally controlled hypertension.  After checking routine labs, you decide to increase the patient’s lisinopril from 10 to 20 mg po qd.  If you calculate the individual points and assign a level of risk, the MDM table for this encounter would look like this:

Since it only takes two out of three elements to qualify for any level of MDM, it is clear that this encounter qualifies for “Moderate Complexity” medical decision-making because of:

• Three Problem Points (one point for diabetes– established problem, two points for hypertension—established problem, worsening)
• One Data Point for reviewing labs
• Moderate Risk due to the management option selected of “prescription drug management”

Tip: The MDM point system provides a repeatable and objective way for the physician to measure the cognitive labor required to address the clinical issues of any encounter. Many physicians systematically underestimate the value of their medical decision-making.

This occurs because there is a tendency to equate “routine” thought processes with “straightforward” medical decision-making which is simply not true. Utilizing the objective MDM point system can help you avoid this self-deprecating pattern of behavior.

FAQs

1. What is Medical Decision-Making (MDM)?

MDM reflects the complexity of cognitive labor performed by a physician during patient encounters, categorized into four levels: Straightforward, Low Complexity, Moderate Complexity, and High Complexity.

2. How is the level of MDM determined?

MDM is stratified based on three factors: the number of diagnoses, the complexity of data reviewed, and the risk of complications or mortality.

3. What are the Problem Points in the MDM Point System?

Problem Points quantify the nature and number of clinical problems addressed, ranging from 1 point for minor issues to 4 points for new problems requiring additional workup.

4. How are Data Points calculated?

Data Points reflect the complexity of data reviewed, with points assigned for ordering or reviewing tests, discussing results, and reviewing old records, among other factors.

5. Why is the MDM Point System important?

The MDM Point System provides an objective method to quantify cognitive labor, helping physicians accurately reflect the complexity of their decision-making during audits and improving reimbursement potential.

The post Quantifying Your Medical Decision-Making appeared first on Medical Billing and RCM Blogs.

Through ‘Patients over Paperwork,’ CMS established an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, increase efficiencies, and to improve the beneficiary experience. As part of the Patients over Paperwork Initiative, Medicare is simplifying documentation requirements so that providers spend less time on paperwork, allowing them to focus more on patients and less on confusing and time-consuming claims documentation. CMS made the following important changes:

• Clarified acceptable documentation for diagnostic laboratory tests

Before: CMS provided no instructions about how much information was required in the medical record to show a physician’s intent to order lab tests.

After: A signed order, a signed requisition or a signed medical record that supports the physician/practitioner’s intent to order tests (e.g. ‘order labs, ‘check blood’, ‘repeat urine’) can satisfy the order requirements for labs.

• Provided an exception so that physicians acting as suppliers do not need to write orders to themselves.

Before:  The manual did not provide an exception to the written order requirements for physicians that provide DMEPOS to their own patients (in accordance with self-referral laws).

After: A physician acting as a supplier does not need to write to him/herself an order. We will consider any medical documentation (e.g., progress note) with all necessary information as meeting the requirements for an order.

• Eliminated the requirement that physicians indicate wherein the medical record certification/recertification elements can be found.

Before: Information contained in other provider records, such as physicians’ progress notes, need not be repeated in the certification or recertification statement itself. However, the regulation required physicians to note page numbers where that information could be found.

After: Physicians do not need to reference page numbers in their certification or recertification statements.

• Explained that a signature and date is acceptable verification of a medical student’s documentation of an E&M visit performed by a physician

Before: As of January 1, 2018, a teaching physician does not have to re-document a medical student’s notes of an E&M visit, but can verify them. Our instructions didn’t specify what acceptable verification is for medical review purposes.

After: If a teaching physician chooses to rely on the medical student documentation and chooses not to re-document the E&M service, contractors will consider this requirement met if the teaching physician signs and dates the medical student’s entry in the medical record.

• Simplified the requirements for preliminary/verbal DMEPOS orders

Before: CMS provided no clear instructions about whether preliminary (verbal) orders for DMEPOS items were conditions of payment.

After: Suppliers may dispense most items of DMEPOS based on a verbal order or preliminary written order from the treating physician. However, Medicare medical review contractors will look to the signed, written order to see if the item meets our payment requirements.

• Clarified DMEPOS written order prior to delivery date requirements

Before: There was confusion about whether contractors needed to verify that a written order was received by checking for a fax transmittal date or a date stamp.

After: If the written order is dated the day of or prior to delivery there’s no need for affirmative documentation of its being ‘received’.

• Clarified proof of delivery (POD) requirements

Before: The Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) help CMS oversee the DME benefit. Some DME MACs were routinely auditing suppliers for proof of delivery for every claim they reviewed. Suppliers maintain proof of delivery but often fail to meet a technical requirement necessary for compliance.

After: New guidance advises MACs to request proof of delivery documentation for DME items only if it is required as a condition of payment, for example, as a written order prior to delivery for Power Mobility Devices. The guidance also simplifies CMS documentation instructions. While suppliers are still required to keep proof of delivery for every item they bill and may be requested to provide such documentation to other review entities, this should reduce the number of paperwork suppliers is required to submit to MACs during the medical review.

• Clarified signature requirements

Before: CMS contractors denied claims when a nurse initialed a medication administration log instead of including a full signature.

After: We’ve clarified guidance to explain that providers ultimately responsible for the beneficiary’s care must sign the medical record. Claims won’t be denied if a support care provider, such as a nurse documenting chemotherapy, doesn’t sign part of the record.

• Clarified medical review of inpatient rehabilitation facility (IRF) claims

Before: IRF claims were denied even though patients needed and could benefit from an inpatient rehabilitation program.

After: CMS clarified guidance to its contractors, requiring them to use clinical review judgment to determine the medical necessity of the intensive rehabilitation therapy program based on the individual facts and circumstances of the case, and not based on any threshold of therapy time.

• Clarified billing for Immunosuppressive Drugs

Before:  If a supplier mailed an immunosuppressive drug shortly before the end of a beneficiary’s inpatient stay and used the mailing date as the date of service, the claim could be rejected. This happened because the claim’s date of service preceded the beneficiary’s date of discharge.

After: We clarified that a supplier can use the discharge date as the date of service if mailing one or two days before discharge.

• Allowed teaching physicians to verify student’s Evaluation and Management visit notes

Before: Teaching physicians had to re-document most updates even when they concurred with what the medical student wrote in the patient’s medical record.

After: We revised the manual instructions to allow teaching physicians to verify in the medical record any student documentation of billable services, rather than re-documenting the work.

FAQs:

1. What is the Patients Over Paperwork (POP) Initiative?

The POP Initiative aims to streamline CMS regulations to reduce unnecessary burdens on healthcare providers, allowing them to focus more on patient care instead of paperwork.

2. How has CMS simplified documentation requirements for lab tests?

Providers can now satisfy lab test order requirements with a signed order, requisition, or relevant documentation showing intent, eliminating previous ambiguity.

3. What change was made regarding DMEPOS orders for physicians acting as suppliers?

Physicians no longer need to write orders to themselves; any relevant medical documentation can serve as an order, simplifying the process.

4. What clarification was provided for proof of delivery (POD) requirements?

CMS now requires proof of delivery documentation for DME items only when necessary for payment, reducing the paperwork burden for suppliers.

5. How do the changes affect teaching physicians verifying medical student notes?

Teaching physicians can now verify medical student documentation without needing to re-document, streamlining the process and reducing redundant work.

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How can Physicians achieve better ROI with claim status checking?

You as a physician are busy, the staff is caught up, but staying on top of claims statuses is as important, as checking the patients. Proactively monitoring can keep small issues from turning into claim denials. As a matter of fact, it takes around 5-12 minutes per claim to check status manually and that adds up fast. Most of the time, the healthcare staff spends more energy only to find that the claims in question don’t have a status yet.

A tremendous amount of time is wasted by revenue cycle management experts checking on claims where nothing has happened yet. A technology-driven, automated approach to claim status checking/monitoring ensures resources are being expended where they will do the most good, which is working only those claims that have already been identified as having issues. Medical billing and coding companies are your go-to man in such a scenario if you feel the in-house department has other issues to take care of.

In this changing climate, revenue must be managed differently to ensure that the value delivered to patients is reimbursed appropriately both in terms of accuracy and timeliness.

Understand claims with the context of revenue cycle management

For hospitals and doctor’s offices to ensure that their claims are paid, they must first understand how the different components of claims management affect compensation.

Whether you call it revenue cycle or protecting your reimbursement, success will depend on making many improvements simultaneously. It’s not just one small thing that you fix, but making several improvements and making them simultaneously through the process from pre-care to zero balance.

The negative impact improper claims status tracking can have on reimbursement are significantly more pronounced in clinical settings where resources dedicated solely to the revenue cycle are often lacking.

Healthcare experts working over claims management realized it early on that physicians are running the business, but they are not businessmen. They are caregivers, but still they have to manage their practice as a business and claims processing and management was the sand in the gears of practice management.

According to experts, those healthcare organizations and providers succeeding at reimbursement take into account and address how each of the variable components of the patient-provider interaction fit into the revenue cycle and could introduce gaps leading to loss or risk:

Here are some points to ponder upon:

1. Pre-service (pre-registration, pre-authorization)
2. Process of care
3. Process integrity practices (chargemaster, coding compliance, clinical documentation)
4. Medical Billing Services (customer support, collections, and follow-up)
5. Administrative services (contract management, fee schedules, debt collections, managed care contracts, denial management)

When you classify your practice or your hospital across these five areas you are then able to address within each of these components – what is working and not working – what are the industry standards –  where are your peers compared to where you are, and lastly what you need to do to get to the next stage and then beyond that.

In simple terms, refining reimbursements begins with assessing the current state of affairs. Experts recommend that physician practices and hospitals pay special attention to three broad functional areas, which are financial, technical, and operational.

Keep an eye open for payer rules and denial rate calculations for a positive ROI

The first step to better the ROI is identifying denials and the reasons behind them. However, saving important claim denial statistics may not be as easy as plugging numbers into a formula.

This is because providers may not have access to claims denial data from payers. Payers many a time are tentative to release the data, especially how often they reject claims, because of competition. They tend to keep the information secluded or restricted to prevent potential customers from passing them up for a payer with a lower denial rate.

As a result, industry averages for claims denial rates generally differ from one report to another. For example, a private sampling agency might report that the denial average overall is between 5 percent and 10 percent, whereas the Government Accountability Office (GAO) found that up to one-quarter of claims are denied.

Do remember that Claims status checking/tracking and medical billing teams not only draw data from across the healthcare organization, but they must also manage different payer rules and medical codes. Using manual processes could slow productivity given the plethora of data needed to successfully manage denials. So go for automated tools.

The post Physicians achieving Better ROI with Claim Status Checking appeared first on Medical Billing and RCM Blogs.

For decades, government plans such as Medicare and Medicaid have typically paid doctors and hospitals less than private plans, and even less than the actual costs of the services in some cases. Health care providers covered their losses by raising prices to patients with private insurance.

This “cost-shifting” contributed to increases in the costs of employer and individual health insurance plans. As private health insurance became prohibitively expensive for many Americans, more became uninsured or covered by government plans. And as more participants in government plans strained state and federal budgets, the gap between payouts from Medicaid vs. private insurers became even larger.

How Medicaid Expansion Affects?

What Medicaid expansion means for your practice? If you are in one of the 20 states that have not expanded Medicaid or if your state has expanded Medicaid eligibility but your practice does not accept Medicaid patients obviously that part of the legislation will not affect you.

Clearly, hospitals and private medical practices in states that expanded Medicaid saw a significant increase in Medicaid revenue, along with decreases in uncompensated care. This translated into improved profit margins compared to hospitals in states without the Medicaid expansion.

Clearly, hospitals in states that expanded Medicaid saw a significant increase in Medicaid revenue, along with decreases in uncompensated care. This translated into improved profit margins compared to hospitals in states without the Medicaid expansion.

With many of the patients not having had access to regular care before, they are more likely to have untreated chronic conditions.

For physicians, expansion means fewer uninsured patients. That translates to reducing the volume of uncompensated care and uncollectible accounts. In states that refused to expand, many citizens will continue to be in the gap of the uninsured because they fall below the income level required to purchase coverage through Obamacare’s marketplaces, but they do not qualify for Medicaid. As a result, physicians and hospitals will continue to absorb the uncompensated costs. This means physicians and hospitals in Colorado have fewer uninsured patients overall.

Additionally, the preventive services expansion alone can potentially stave off serious complications that could increase the cost of uncompensated care even more if left untreated. It is the state’s hope that physicians who previously did not accept Medicaid will now start doing so.

The Medicaid expansion portion of the Affordable Care Act calls for coverage of individuals up to 130 % of the poverty level, or an additional 15 million Americans, starting in 2014. In return, the federal government would pick up all healthcare costs for the first few years, and 90 percent of expenses after that.

In an effort to ensure that physicians don’t shut their doors to Medicaid patients for lackluster reimbursement, the health law will increase Medicaid pay to primary-care doctors to Medicare levels in 2013 and 2014, which will increase reimbursement by an average of about 35%, according to the American Academy of Family Physicians.

Originally, the law mandated that states that did not adopt the Medicaid expansion would no longer be eligible to receive any Medicaid funding at all. But with the High Court’s decision to let states decide whether to accept additional funding to expand their existent Medicaid programs, the future of healthcare coverage for the lowest-income citizens is no longer clear cut.

Already, governors in a number of conservative-leaning states including Kansas, Nebraska, and South Carolina have said they would have trouble affording any additional costs even if the federal government picks up the bulk of the tab. Others have vowed never to participate in the program. Democratic congressional leaders, meanwhile, have issued press releases adopting the merits of expanded Medicaid coverage.

It seemed pretty confident that all states, eventually, would accept benefits and terms of the Medicaid expansion the same way all states came around to enrolling in the original Medicaid program unveiled as part of the Social Security Act of 1965.

Conclusion

Still, so many questions remain as to how this will play out for physician practices over the next several years. Will practices whose physicians already treat Medicaid patients see their profits fall because reimbursements for these patients are lower than for patients with Medicare or third-party insurers? Or will the influx of new patients give fledgling practices a financial boost?

The practices in every state should brace themselves for the potential for an increase in patients by making sure their existing technology is robust enough to handle the volume.

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Here are a few insights on patient engagement in value-based reimbursement:-

1. A different process for engagement

Every patient is a person and mostly isn’t happy while coming to meet you. The patient is looking for care, usually; the care results in one-way communication. Patient engagement is close to zero.

Some of the beneficial factor for physicians

1. Compliance benefited patients.
2. Improved patient diagnoses and fewer no-shows.
3. Better facility marketing.

A patient has a better engagement with physicians who are independent as it gives more time for you to spend with the patient for interaction and improve the engagement. For physicians working in a group, this could be the best reason to outsource medical billing so you can concentrate on your patient care.

2. Better cost engagement

Improved care utilization and systematizing the most effective service for the patient according to each engagement will enable you to put forth a better value-based result.  It will also add the necessary preventive service for care that would cut down on long-term costs.

3. Consistency in communication

You can be more proactive when it comes to approaching the potential group of employees or employers which might lead you towards getting a wider range of engagement for the practice. For a physician group it’s easier with approaching a group of employees and then an insurance company, this would lead to building consistent communication with a group of employees leading to better engagement with future patients on the value-based reimbursement for the procedures and diagnoses.

For consistent communication between the payers- insures and patients along with physicians their needs to be a flow of information from both sides which would get the reimbursement flowing.

Practices can employ a strategy which is “Take the wheel”. Follow the recommendations given by the payers to small practices that take the lead on messaging the patients. The particular program or intervention that a payer of a small practice.

For Example, if a patient needs a cancer-preventive program, the payer needs to cover it through out-of-pocket payment and the employer insurance will be willing to pay part of it. If all the stakeholders get in the loop even as the physicians want to see in continuous condition loop, and everyone benefits. The main example is to engage the necessary parties for better value-based care and patient engagement.

4. Patient Engagement

Patient portals can act as a technology bridge between patients and physicians which would improve the service. The IT companies will develop an advanced function such as a more user-friendly app to encourage more engagement with user-friendly apps that encourage engagement and involvement.   This will not only promote your patient engagement it will also help you keep track of the necessary components of patient care.

To improve your patient engagement under the value-based reimbursement model, you will need a team of billers and coders so that you promote your patient engagement without hampering your revenue.  For more info on medical billing click here or call us on – 888-357-3226.

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Below mentioned are the facts that you should know:

1. According to several reports, up to 85 percent of medical bills contain coding mistakes resulting in $70 billion in estimated losses.

2. 45 % of claims submitted to Medicare are incorrectly coded.

3. In 2012, approximately $93 billion was added to Medicare and Medicaid spending as a result of fraud.

Any medical practice that is serious about improving its profitability starts with its data stream first. Practices lose out on millions of dollars every year because of avoidable medical billing and coding errors. Switching over to an automated system for data input, re-evaluating office regulations to be in compliance with the latest standards, and double-checking all outgoing documentation is a good start. However, it is better to hit the problem at its source – during employee training.

Your Staff Is Your Biggest Asset

Like any business, your employees are your biggest asset. Just like any asset, you must take care of your employees in order to benefit from their full potential. For this reason, offering medical coders medical billing training is imperative to operate a successful medical practice. Providing training will let them grow and mold your medical staff to fit the needs of your practice.

Providing your medical billing coders with medical billing training offers the following benefits:

1. It Helps Builds Morale

Offering medical billing training to your medical coder sends a message that you are invested in their success. It may help them feel valued as an employee and in return increase their productivity.

2. It Increases Office Productivity

In line with the above, offering medical staff training teaches employees new techniques and tools that can make them more efficient at their job. This increased efficiency can increase office productivity which may result in increased profitability.

3. Risk Management

Training employees in the proper way to handle certain situations, such as sexual harassment or emergency situations may help your practice mitigate risk.

4. Reduced Turnover

Because your employees feel valued and well equipped with the information and tools necessary to perform their job and perform it well, medical staff training can reduce turnover.

5. You Portrayed Enhanced Image of Your Medical Practice

Providing training opportunities for your employees can help to fuel your reputation among patients as well as competitors. Patients will benefit from your medical staff training endeavors and since satisfied patients are your most valuable referral source, you may experience an influx of new patients as a result.

Areas where your medical billing coders’ benefits from medical billing training include are:

1. Technology

This includes EMR/EHR training, training on how to operate medical equipment, or even basic computer skills.

2. Better Communication

Medical billing training courses helps to enhance communication to better communicate with patients, clinic staff, and insurance providers.

3. Problem Solving

Training your staff in critical thinking and problem-solving may help them react better in certain situations as well as work better independently, therefore accomplishing more.

4. Team Collaboration

Teamwork is an important part of operating an efficient medical practice. Offering medical staff training on how to collaborate and better function as a team is imperative.

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