What Are the Best Practices To Include In Medical Billing Quality Assurance Program?

The US healthcare industry is continuously growing. A result of this evolution is the ‘’revolutionized volume-based healthcare services’’.

Modifications were made to improve patient experience, patient empowerment, and better-quality healthcare standards. Unluckily, we are still not where we should be, for example, to reach an empowered and progressive healthcare system. How significant are the medical billing services? Is there a checklist for RCM?

The cost-effective constituent that is the most concerning thing about the healthcare industry right now is_ the cost factor which is evenly unsettling for both providers and patients. Consumers talk about how healthcare programs are not in their access either their coverage plans don’t cover it or they can’t afford it. When will medical practices make efforts to look for streamlined revenue cycle management?

Essentials For Efficient Medical Billing Services

  • Processing of data captured from the front-end office.
  • Code services/diagnostic procedures according to the latest ICD-CM-10 or CPT codes.
  • Follow the insurance companies’ guidelines and create medical claims according to the latest policies.
  • Bill each rendered services according to the specific procedures provided to the particular patients.
  • Submit the medical claims to the insurance payers and wait up for the Explanation of Benefits (EOB) statement.
  • Providers get paid after the acceptance of medical claims by the insurance company.

Many things may go wrong throughout the revenue cycle management and overall medical billing & coding system as the process demonstrates. It is indeed stressful to manage everything while following HIPAA rules and staying compliant with these regulations. It becomes even more frustrating for providers when they don’t get the required results at the end after all the cumbersome and tiring working hours. Thereby, a good practice beforehand is to ensure quality checks.

Professional medical billing companies can make survival possible for medical practices. Below are some medical billing quality assurance checks which may help providers to increase their business efficiency. These will work out in the best way possible for them.

  • Cost-Collection Percentage

This phase is significantly notable for those facilities that manage their medical billing & coding in-house. Take a total of all the costs spent during the medical billing & coding and follow-up services. Assure involving other costs such as the expense required for staff benefits such as paid vacations, annual bonuses, health insurance, sick leaves, etc. Divide these costs by the whole monthly income. Check the % and evaluate if it is more than four percent. If that is the case. Providers must take expert support to streamline their billing and collection processes.

  • Professional Support To Grow

This might not be so productive as a medical billing outsourcing agency when you spend a lot to manage the billing process. An experienced billing firm has the expertise to reduce errors and offers specialty-specific billing services. Billing experts implement approaches that put a stop to high A/R rates to a significant level. This way you get to enhance monthly collections with appropriate coding techniques and proper documentation.

  • A/R Recovery Management

This is an important tip for healthcare providers. Keep an eye on your A/R. Because the days in which you get reimbursed by insurers have a significant role in determining your revenue performance. If it takes more than 90 days you must tackle this situation but if it is between 30-60 days that is ok. There is a good chance that your claim might go in vain. You may want to settle this issue after ninety days. You must know how things go with insurance agencies.

Sometimes unexpected things happen. Moreover, not every provider receives reimbursements as predicted. Each healthcare organization to some extent must write off expenses depending on the payer mix (% of revenue from private/government payers, patients), volume, and specialty-specifics, etc. Moreover, you may not be able to meet your expenses efficiently if the waived off charges are above a certain limit.

  • Clean Claim Rates

It is a good sign for healthcare RCM when the rate of accepted claims by the payers in the first attempt is high. Moreover, if claims are clean and there are only fewer errors in the submitted claims it dramatically cuts down your costs. Ultimately, it leads to higher profits when there will be fewer expenses.

  • Payer Mix Strategy

When you send different claims to various payers like private payers, Medicare, government payers, etc_ this shows the payer mix. When medical billing experts adopt this strategy this helps you to file claims according to the particular rules of various insurance agencies. This way, providers become able to increase revenue percentage from each authority. On the other hand, if you have not yet adopted this strategy it’s time now to give it a try.

Check for those areas of payer mix strategy that cover more commercial payers and lesser self-pay or CMS. It leads to lower overall income when the percentage would be high for governmental payers’ revenue. Typically, in comparison to governmental payers, the commercial payers pay a lot but in that case, oftentimes A/R days exceed slightly.

  • Medical Billing Auditing

You must identify the areas where your revenue lag by reviewing common mistakes that are leading to impacting your business’s financial health. You must be aware of the fact that everything in your practice is going right. At this point, an audit is a complete medical billing quality assurance check_ that helps you to identify the modern standards, create claims, and also put light on shady areas that need improvements.

For that particular matter, CMS has designed a measure called CERT audit_ which helps you to stay compliant with government bodies’ guidelines and maintain the accuracy of the claims according to such standards. CMS generally accepts an error rate of about 6%. However, you must ensure that your medical claims have no error this way you will get paid completely.

  • Comparison With Competitors

Another benchmark for efficient healthcare revenue cycle management is comparing your statistics with your competitors. Check if you both are checking the same number of patients at the same time. Estimate if you are receiving complete reimbursements at the end of the day?

  • Conclusion

For reducing the number of unpaid claims, the above-mentioned quality checks are part of an ongoing quality assurance program. Considerably, this enables you to have insights into the functioning of your revenue cycle management. When you adopt these quality checks, you become able to generate cost-effective, productive, and automated outcomes. Henceforth, professional medical billing companies can also help you to generate revenue strategically with the help of optimized billing methods.


Omotimehin Nelson is a Nigerian award-winning content writer. He derives passion for creative writing. Join me

%d bloggers like this: