The overpayment of Medicare and Medicaid Service Centers may prove to be a huge cost burden for providers and commercial payers because they will then have to pay the government and face legal dangers in some cases. But avoiding this situation is not complicated. It requires a careful review of the revenue cycle management process, and new technologies can help.
The overpayment of CMS can reach millions.in a Report released in August, The Office of the Inspector General of the Ministry of Health and Human Services found that CMS paid providers $1.9 million more than they needed for chronic disease care management services in 2017 and 2018.
Not only that, but the scrutiny surrounding overpayments is also heating up. last month, Court of Appeal Order UnitedHealth and other Medicare Advantage insurance providers report overpayments by CMS for treatments that are not supported by the patient’s medical records.
Overpayment usually occurs because the process is not simplified. For example, double billing has been a problem for providers and payers for decades.
Some payers take a “one-and-for-all” approach, which means that they first focus on paying the claim and then review it, which can lead to double billing. Help Rebecca Barnes, the product line manager of the revenue cycle management company Availability, In a telephone interview.
Ideally, the payer will review and update any of their existing systems, including the claim editing process, Involves verification The declaration code submitted by the provider is correct. Barnes said this helps improve the accuracy of payments when a claim is filed through their system for the first time.
Similarly, providers need to be cautious when recording patient visits.
They need to record what happened during the office visit, the patient’s condition, whether the patient has multiple diseases, and other details,” said Chief Operating Officer Lynn Carroll. HSBlox, A medical financial technology company.
Then, before submitting a claim, they need to go through a cleanup and review process to determine whether the claim is accurately billed and whether it is a service reimbursed by CMS.
“[But] It is impossible to explain all the permutations, changes and anomalies that caused the overpayment [or] Pay less,” Carol said in a telephone interview.
This is where technology can play a huge role.
On the provider side, automation can help catch errors at the front end of the process, and for commercial payers who provide government programs, it can help simplify the back end.
Carroll said that machine learning in particular can change the claims review process. For example, HSIBlox applies machine learning methods to verify patient eligibility and confirm the accuracy of the CPT code used, which indicates how much CMS will pay for any given service.
Another technique that is useful for both suppliers and payers is the claim editing tool.
“[These tools] It can help with compliance because they will check for errors before submitting a claim,” said Availity’s Barnes. “This includes not only important government standards, but also industry standards for billing and reporting practices. “
Overpayment is not just the result of a system error in the provider or payer.
In many cases, overpayment occurs after signing the contract Between provider and payer Renegotiation with the government.
Terry Blessing, senior vice president of customer development, explained that this may cause the provider to pay for the services outlined in the previous contract, but not in the most recent contract, leading to overpayment. access, A provider of health care revenue cycle analysis and automation.
Efficient contract management software can help prevent this from happening.
“[This software] It will tell you which service date is related to which contract. Once the contract is confirmed, it will tell you the reimbursement amount for the service based on that date,” Blessing said in a telephone interview.
Most importantly, avoiding overpayment issues requires precise audits and reviews, as well as the ability to keep up with changing medical reimbursement guidelines.
“Today’s coding and billing fields have too many guidelines and rules, and I don’t know that there is one person who can keep up with all these guidelines and rules,” said Barnes of Availity. “People can make mistakes, and technology can help reduce this.”
Photo: adventtr, Getty Images
