Three Things

Suffice it to say, 2008 is turning into an interesting election year. Suffice it to say, further, that the topic of healthcare has probably never been more in the background than this year. Of course, that's easy to understand, what with the war and the economy being on the front pages every day.

However, even when healthcare is in the news, it's almost never good news. Keeping it to our own industry, all we hear about are payment cuts and takebacks most of the time, and it's pretty ugly stuff. It seems that every day we hear about another hospital that's paying a large fine for some sort of billing improprieties, or how, because of the budget, Medicare's getting slashed by another 50% (okay, maybe not quite that much), and how hospitals and physicians are already making too much money so let them shoulder the burden. And, by the way, they still expect charity care levels to be high for non-profits; after all, that's what the tax break thing is all about.

It seems like the healthcare industry is a mess, and it's possible that it is. But we're stuck with it because, unlike things such as technology, healthcare is never going away. People are always going to need some type of healthcare, and the people who provide it are always going to want to get paid, and they're always going to hire people who are going to get paid, so we might as well try to figure things out to make it all better for ourselves.

First, let's take a look at the top three issues that get in the way of the success of the hospital revenue cycle's, and therefore medical business offices, success:

1. Paperwork. This has always been the biggest issue for billing departments, and healthcare in general. It seems like even those payers who accept electronic bills want some kind of paper on the back end. Sometimes it's not good enough for those insurance that require pre-authorization to give them a number; sometimes they want you to actually prove they gave it to you. Having to produce medical records is another thing, because some insurance companies request medical records on everything, and even if you can supply it electronically they sometimes say they need you to mail it to them. Some insurance companies want you to submit on their own forms; insurances like compensation and no fault actually have extra forms that have to be completed. Let's not even get into Medicare's required forms.



2. Coding. Most billing departments don't understand any of the codes that are prominent on bills, and that's a problem. It's a problem because it means they can't diagnose badly coded claims on their own, instead having to hope that both their charge masters and their medical records people get it right all the time. However, even the best medical records departments sometimes don't know that Medicare states this or that CPT code is only legitimate with this or that ICD-9 code, and billing departments sometimes don't think to look at this as a reason claims are being denied. It's not really their fault, because the rules are confusing, and Medicare has a way of wanting something different than the Blues, who wants something different than Medicaid, who wants something different than compensation does in some states,... on and on. Goodness, in many states Medicaid is creating its own procedure codes, and many special state programs sound nice, but not only don't pay enough but also don't work well in conjunction with other insurances. At the same time, each year there are new codes for each of these, new rules for how to use revenue codes and modifiers, new bundling rules, and few specifics, such that most facilities are left to figure out for themselves what the wording of each of these codes means, and how they're supposed to be used.



3. Fear. Both the federal and state governments have done a great job of instilling fear into almost everyone as it concerns medical billing, and there's this nice trickle down effect that can be paralyzing. I remember the fear that was initially caused by the HIPAA in 1996 and this magic word "fraud" started coming into prominence. The success of the OIG in taking many hospitals to task is what's spawned the RAC audits that are presently scaring hospitals. On the state level I know of many hospitals in my home state that, back in 1999, were afraid to send out compensation claims because of some change in the state regulations that seemed like there could be punitive responses to claims not properly billed; my hospital kept billing because I read the law differently, and didn't want to impede my cash flow. The fear of things going wrong has many administrators and managers looking at the billing office to try to determine if they're doing the job they're supposed to be doing, but unfortunately, don't have the background or knowledge to know how to do it, and then are unsure as to which, if any, consultants they can bring in to take a look and help them out.

That's what medical billing professionals are up against, and, unfortunately, a lot of that isn't anything they can do something about. However, there are some things that can be done, because no one is as much of a victim as they might appear to be. Here are three things that medical business offices need to do to take control of their circumstances:

1. Have a free flow of information. I almost used the word "educate" there, but it's not that simple. Information has to flow throughout the facility, as much as throughout the billing office. Every hospital gets new information at least weekly, but everyone might not know who's getting what. There should be hospital policies that concern the distribution of information. There should also be departmental policies for how information should be distributed and shared. Quite often everything stops with the director of the department; that doesn't help anyone. Also, directors and supervisors need to allow themselves to learn from their employees instead of shutting them down, as if they don't know anything. Many times a billing person may know about new rules and regulations through the course of working outstanding claims, but if there's no encouragement to share information, they'll keep it to themselves; that also doesn't help anyone.



2. Have some standards, departmental and otherwise. I've talked in previous newsletters as to why it's critical to monitor performance and let employees know just what's expected of them. Here I'm taking it much further. If you know there's an insurance company that expects a certain thing, there should be a standard for making sure that information is obtained in the least obtrusive manner possible to help get claims out the door faster and paid on time. There should be a standard for how to pass information along to other departments to help your department do their job better, whether it's registration, medical records, or an ancillary department. There should be a standard on how much education each employee will be given throughout the year. There should be a standard of figuring out how to make billing easier, such as setting up more electronic billing, having more or verifying edits that hold up bills, figuring out ways to check statistics on a more accurate level, even determining staffing levels and figuring out ways to be more accommodating to your employees, all of which helps performance in some fashion.



3. Don't be ruled by fear. Earlier I said fear can be paralyzing, and it can. Fear makes you think way too much before acting, if you decide to act at all. There is no such thing as perfection; even the best chocolate you've ever tasted can be beaten by a chocolate you've never heard of yet. If you stay informed, the mistakes made will either be rare, or something that had nothing to do with your department, but rather something that came about because of the actions of another department. Fear is an emotional response to the unknown, sometimes even when you know what the unknown is. If you believe in your heart and mind that you're doing the right thing, then go ahead and do it. Remember, though, it always helps to bring other people into the process, especially knowledgeable people.

No, it's not an easy job we do, and there are a lot of rules and regulations, but it can be satisfying and rewarding if we do the things we can do, and not worry so much about the things that are out of our control. But the better we communicate, the better we operate.