Important Modern Insights and Research into Pre- and Post-Payment Audits
The relationship between pre-bill and post-bill auditing forms a cohesive integration in the revenue cycle. Pre-bill audits prevent errors, boost efficiencies, and safeguard revenue, while post-payment audits provide retrospective insights into navigating payer disputes with evidence-based knowledge. The following developments in technology and innovation have enhanced the effectiveness and efficiency of audits. By integrating these latest technologies, healthcare organizations can improve fraud detection, enhance accuracy, and improve overall financial integrity. The 6 Most Important Developments in Pre-and Post-Payment Audits Advanced Analytics and Artificial Intelligence The integration of advanced analytics and artificial intelligence (AI) technologies has significantly advanced pre-payment and post-payment audits, enabling more accurate identification of potential billing errors, streamlining the audit process, and enhancing overall effectiveness (Huang et al., 2022). In pre-payment audits, AI algorithms analyze large volumes of claims data, identify patterns, and flag anomalies, helping auditors prioritize high-risk claims for review. The use of predictive modeling and machine learning algorithms improves accuracy in identifying potential discrepancies, reducing the burden on auditors. Similarly, in post-payment audits, the application of data analytics and machine learning techniques revolutionizes fraud detection. Advanced algorithms analyze vast amounts of claim data, identifying patterns, anomalies, and potentially fraudulent activities with greater accuracy and speed. This enables auditors to proactively detect and investigate suspicious claims, leading to improved fraud prevention and financial integrity. Real-time Claims Adjudication Real-time claim adjudication systems play a crucial role in both prepayment and post-payment audits. By leveraging these systems, payers can validate claims against billing guidelines and medical policies in real-time, ensuring accurate and compliant payments (Arnold, 2023). In pre-payment audits, the incorporation of automated rule engines and decision support tools allows payers to proactively identify errors or improper billing practices before claims are paid. Real-time adjudication systems provide instant feedback on claim submissions, enhancing provider education and compliance. This immediate validation of claims against guidelines helps prevent payment errors and ensure payment accuracy. Likewise, in post-payment audits, real-time claim adjudication systems help auditors promptly validate claims, detect inconsistencies, and investigate suspicious activities. By providing instant validation and feedback, these systems contribute to improving audit efficiency and effectiveness. Robotic Process Automation (RPA) Robotic Process Automation (RPA) technology has brought significant advancements to both prepayment and post-payment audits. By automating repetitive and rule-based tasks, RPA streamlines the audit process, reduces processing time, and minimizes human errors (Dhanashree, 2022). In pre-payment audits, software robots deployed in RPA assist in tasks such as data entry, verification, cross-referencing multiple data sources, validating provider information, and conducting eligibility checks. These automation capabilities enhance the efficiency and accuracy of pre-payment audits. Similarly, in post-payment audits, RPA technology assists auditors in data validation and verification processes, improving overall audit efficiency. By automating tasks such as data entry and verification, RPA minimizes manual effort, accelerates the audit process, and reduces the likelihood of errors. Machine Learning for Fraud Detection Machine learning techniques have become invaluable for fraud detection in prepayment and post-payment audits. By analyzing claims data using advanced algorithms, machine learning models can identify patterns, anomalies, and potentially fraudulent activities more accurately and quickly (Stiernstedt & Brooks, 2020). In pre-payment audits, machine learning algorithms analyze large amounts of claim data, enabling auditors to identify high-risk claims requiring further review. By proactively detecting discrepancies and potentially fraudulent activities, auditors can improve fraud prevention and ensure financial integrity in the payment process. Similarly, machine learning techniques in post-payment audits revolutionize fraud detection by analyzing claims data for patterns and potentially fraudulent activities. By leveraging these technologies, auditors can proactively detect and investigate suspicious claims, ultimately enhancing fraud prevention efforts and ensuring financial integrity. Predictive Modeling for Risk Assessment Predictive modeling techniques have emerged as valuable risk assessment tools in prepayment and post-payment audits. By analyzing historical claims data, payer-specific patterns, and industry benchmarks, predictive models can assess the risk associated with certain providers, services, or billing practices (Broby, 2022). In pre-payment audits, predictive modeling helps auditors prioritize their efforts by focusing on high-risk areas and optimizing resource allocation for more effective audits. By utilizing predictive modeling, auditors can identify providers or billing practices with a higher likelihood of errors or irregularities, allowing for targeted investigations and improved audit outcomes. Similarly, in post-payment audits, predictive modeling aids auditors in assessing the risk associated with specific providers, services, or billing practices. By analyzing historical claims data and industry benchmarks, predictive models provide insights into potential areas of concern, enabling auditors to allocate their resources efficiently and focus on high-risk targets. This approach enhances the effectiveness of post-payment audits and increases the likelihood of detecting fraudulent activities or billing discrepancies. Blockchain Technology for Audit Trail Transparency Blockchain technology offers enhanced transparency and integrity in both prepayment and post-payment audits by creating an immutable and auditable trail of claims-related transactions. By leveraging blockchain’s decentralized and tamper-proof nature, auditors gain access to a transparent record of claim submissions, payments, and adjustments (Regueiro et al., 2021). In pre-payment audits, blockchain-enabled audit trails ensure the accuracy and reliability of the payment process. Blockchain records’ transparent and immutable nature simplifies the auditing process and provides verifiable evidence, reducing the chances of errors, fraud, or unauthorized modifications. Likewise, in post-payment audits, blockchain technology strengthens the integrity of the audit trail by creating an unalterable record of claims-related transactions. Auditors can rely on blockchain’s transparency and immutability to verify the accuracy of claims, payments, and adjustments, facilitating more efficient and reliable post-payment audits. In Summary Automated workflows and intelligent algorithms streamline the pre and post payment process, optimizing resources and reducing manual errors. Transparent communication with stakeholders, including providers and insurers, resolves discrepancies efficiently and effectively. Regular monitoring and updates adapt to evolving fraud schemes, effectively combating fraud, waste, and abuse. A well-designed payment scrutiny system ensures accurate identification, minimizes errors, and maximizes recovery opportunities. Billing transparency is a top priority at ClinicMind. We are committed to providing you with easy access to comprehensive reporting. With our intuitive system, you no longer have to jump from portal to portal to find answers. We offer over 50 reports that
Fortis: Chiropractic Payment Solutions
In the intricate world of chiropractic practices, where patient care and business operations intersect, finding seamless and efficient payment solutions is paramount. Fortis, a pioneering player in the field of merchant services, has emerged as a game-changer, offering tailored payment solutions designed specifically for chiropractors. In a recent conversation with Jonathan McAleese, CEO of Fortis, we delved into the roots of their journey, the evolution of their services, and the future of chiropractic payment technology. A Legacy Rooted in Chiropractic Care Jonathan’s journey into the world of chiropractic payment solutions is deeply personal. It traces back to his family’s profound connection to chiropractic care, spanning generations. His father’s transformative experience with chiropractic treatment, amidst the challenges faced during his service in the Marine Corps, laid the foundation for Jonathan’s lifelong commitment to the chiropractic profession. With chiropractors woven into the fabric of his family tree, Jonathan’s upbringing immersed him in the world of chiropractic care from an early age. Genesis: A Pioneering Partnership Fortis’ foray into the chiropractic space was catalyzed by a pivotal partnership with Genesis, a leading provider of chiropractic practice management software. Recognizing the unique needs of chiropractors, Fortis Pay integrated seamlessly with Genesis, offering practitioners a comprehensive suite of payment solutions within their existing workflow. From processing credit card payments to managing recurring billing and beyond, Fortis’ integration with Genesis streamlined practice operations, enhancing efficiency and patient experience. Innovative Solutions for Chiropractic Practices Fortis’ commitment to innovation is evident in its relentless pursuit of solutions tailored to the specific needs of chiropractic practices. From simplifying recurring billing to enabling seamless inventory management, Fortis’ offerings are designed to alleviate common pain points faced by chiropractors. The introduction of features like Paylink, allowing for convenient online payments, and forthcoming advancements in inventory management underscore Fortis’ dedication to empowering chiropractors with cutting-edge technology. Looking Ahead: Redefining Chiropractic Payment Technology As Fortis continues to innovate and expand its suite of services, the company remains steadfast in its mission to be a long-term partner to chiropractic practices. Jonathan’s vision for Fortis transcends mere transactional relationships; instead, he envisions a collaborative journey, where Fortis’ technology evolves in tandem with the evolving needs of chiropractors. By staying true to their core principles of reliability, innovation, and customer-centricity, Fortis aims to be the go-to solution for chiropractic payment technology for generations to come. Conclusion In a landscape where technology plays an increasingly pivotal role in healthcare delivery, Fortis stands out as a beacon of innovation and reliability in the realm of chiropractic payment solutions. With a rich legacy steeped in chiropractic care, a commitment to continuous improvement, and a deep understanding of the unique needs of chiropractors, Fortis is poised to revolutionize the way chiropractic practices manage their payments. As chiropractors navigate the complexities of running their practices, Fortis Pay remains a trusted partner, empowering them to focus on what matters most: delivering exceptional care to their patients. Genesis Nation, take note: the future of chiropractic payment technology is here, and it’s powered by Fortis.
Straight-Through Billing
Medical billing complexity and massive volumes of daily claims render manual claims processes incapable of protecting both the provider and the payer from underpayments, overpayments, and billing compliance violations. Straight-Through Billing (STB) addresses complexity and volume processing problems by automating the majority of the claim flow and focusing the billing follow-up specialists on exceptions only. An STB process flags problems routes them for follow-up and enables online correction and resubmission. The STB methodology implements billing service transparency and focuses management on strategic process improvement opportunities. Straight-Through Billing integrates the billing process into the practice management workflow, automates the vast majority of transactions, focuses manual labor on exceptions, and establishes a process for continuous improvement. Remember: Straight-Through Billing offers a comprehensive approach to improving the billing process, integrating various components, and promoting continuous improvement. Practice Management Integration First, integrated practice management and billing workflow connects patient scheduling, medical record management, and billing into a single process. Every participant in the practice management workflow receives a unified and coherent picture of the practice workload, patient and provider location, resource availability, and cash flow. However, integrated with Electronic Health Records, practice management systems are more beneficial. Electronic health records (EHR) are digital formats of a patient’s chart. They contain all the information about a patient’s health. This includes medical history, allergies, immunizations, previous treatments, medication history, past diagnoses, history of substance abuse (if any), and so forth (Shah, 2021). Transaction Automation Transaction automation streamlines and expedites the billing process by automating claim validation, payer message reconciliation, and billing workflow management: Automated claim validation eliminates errors downstream and reduces processing time because it flags errors before submitting the claim to the payer. Automated claim message reconciliation eliminates the costly search for the original claim and standardizes message communication, eliminating the need to decipher the (often cryptic) payer’s message. Automated billing workflow management drives the follow-up discipline required for the resolution of claim denial and underpayment incidents, and it establishes a high degree of process transparency for all billing process participants, resulting in full and timely payments. Automated billing increases the net collection rate due to quick claim turnaround and efficient follow-up. Respond to your denials within 5-21 business days of receiving them, using our Daily Denial Email Alerts (Qureshi, 2022). Focus on Exceptions Focusing manual labor on exceptions requires timely exception identification, routing to follow-up personnel, online error correction, and rigorous follow-up tracking. Again, process transparency enables tracking exception follow-up as implemented in ClinicMind-like systems. Another significant benefit of automated medical billing is the ability to track and analyze financial data. With this, healthcare facilities can monitor their revenue cycles, identify growth opportunities, and generate detailed financial reports (Polo, 2023). Continuous Process Improvement Finally, a process for continuous improvement requires continuous observability of every process attribute and a modification methodology for both automated claim processing and manual exception follow-up tracking. Straight-Through Billing implements billing transparency by design because billing transparency is an integral attribute of every component of the STB process. It also enables businesses to streamline their billing operations, reduce errors, enhance efficiencies, and improve the customer experience (Ward, 2023). Straight-Through Billing Architecture The Straight-Through Billing systems architecture mirrors the architecture of general Straight-Through Processing (STP) systems developed for the financial services industry. Such systems require effective workflow management, a knowledge-based validation system, connectivity to all process participants (including online data reconciliation), and tracking of problem resolution. Therefore, a typical ClinicMind-like STB system has a three-tiered architecture: Back-end processing engine designed for a high-volume transaction processing environment Middle tier, using Java Servlet technology Front end, using an HTML-JavaScript, zero-footprint client Did You Know? The STB architecture is inspired by the systems used in the financial services industry, showcasing the transferability of advanced processing concepts across different domains. An STB system (e.g., ClinicMind) based on the methodology outlined here implements rich functionality, which allows the following to be automated: Computer-aided preferential patient scheduling Integrated electronic medical records Online computer-aided coding Real-time claim validation and patient eligibility testing Electronic claim submission Payment posting, reconciliation, and verification of meeting contractual obligations Monitoring of audit risk and billing compliance Tracking of denial appeal process Quantitative STB Management Straight-Through Billing methodology allows for quantitative management since the likelihood of the entire process failing can be estimated as the product of such items for each individual workflow step. A ClinicMind-like STB system tracks the percentage of clean claims (claims paid in full, and within the allocated time frame, without any manual intervention) and focuses the management on those process aspects that yield the greatest potential improvement. Thus, STB methodology focuses on exceptions at both the tactical and strategic management levels and can help to improve cash flow and reduce outstanding invoices by providing real-time visibility into billing and payment status (Mielnicki, 2022). Modern Insights and Research In the ever-evolving field of medical billing, staying ahead of the curve is crucial for achieving financial excellence in the healthcare industry. Let’s embark on an exhilarating journey into the future of medical billing, where the convergence of electronic health records (EHRs), artificial intelligence (AI), real-time analytics, and collaborative efforts reshapes the revenue cycle landscape. Brace yourself for a transformative exploration that revolutionizes processes, enhances data accuracy, maximizes financial outcomes, and ushers in an era of unparalleled efficiency and effectiveness in the dynamic realm of medical billing. 1- Role of Blockchain Technology in Billing Systems The seamless integration of electronic health records (EHRs) and billing systems is revolutionizing the field of medical billing. Gone are the days of fragmented medical records scattered across various healthcare organizations. With blockchain at the helm, a distributed EHR ecosystem emerges, ensuring a smooth flow of information between providers. By eliminating manual data entry and ensuring accurate documentation, this innovative technology guarantees accurate and secure documentation, eliminating errors and speeding up reimbursement processes (Cerchione et al., 2022). But that’s not all. Blockchain brings an unparalleled level of data integrity and security, employing cryptographic techniques to safeguard patient information from prying eyes.
Decoding the Complexities of Chiropractic Billing and Coding
With over 16 years of chiropractic practice, Dr. Marty Kotlar from Target Coding brings a unique blend of real-life experience and coding expertise, holding certifications as a Professional Compliance Officer and Billing and Coding Specialist. In this conversation with Genesis, Dr. Kotlar shares his insights and sheds light on the top three mistakes chiropractors commonly make in billing, coding, and compliance. Insurance Practices Dr. Kotlar kicks off our discussion by emphasizing the importance of meticulous tracking in insurance-based practices. He introduces the concept of an insurance tracking spreadsheet, stressing the need to record every payment accurately to avoid potential discrepancies. He also touches on common issues such as copay discrepancies and claim processing errors, urging practitioners to ensure they receive rightful reimbursement. Moving on, Dr. Kotlar delves into the world of codes. He discusses the nuances of time-based codes and non-time-based codes, providing valuable insights into maximizing reimbursement through proper coding. Exploring the intricacies of time-based codes like therapeutic exercises (97110), he unveils the critical factors providers should consider for accurate coding. In the final segment of insurance practices, Dr. Kotlar addresses the challenge of maximizing reimbursement. He shares pearls of wisdom, including the often-overlooked activities of daily living (ADLs) code (97535) and the significance of extremity adjustments. By unraveling the complexity of re-exams and other reimbursable services, Dr. Kotlar provides actionable strategies for practitioners aiming to optimize their revenue in insurance-based practices. Personal Injury (PII) Shifting the focus to personal injury (PII) practices, Dr. Kotlar enlightens us on the crucial role SOAP notes play in building strong cases for attorneys. He emphasizes the importance of documenting “duties under duress” and “loss of enjoyment of life,” elements that can significantly impact the patient’s life post-accident. Dr. Kotlar discusses the potential pitfalls associated with overprescribing in PII cases, cautioning against unnecessary procedures or devices. He sheds light on compliance challenges related to devices like back braces, TENS machines, and home traction units. Additionally, he underscores the necessity of thorough follow-ups to prove the clinical necessity of prescribed items. In this segment, Dr. Kotlar unveils the complexities of fee schedules, dual fee schedules, and the state-specific regulations chiropractors must navigate in the PII landscape. By addressing these challenges, he equips practitioners with the knowledge needed to build strong PII practices while ensuring compliance with legal and ethical standards. Cash Practices Dr. Kotlar concludes our conversation by exploring the nuances of cash practices. He starts by cautioning against misleading advertising practices, emphasizing the need for compliance even in cash-based settings. The discussion then pivots to the intricacies of prepaid plans, highlighting the potential risks associated with mishandling prepaid funds and the necessity of putting money in escrow. The conversation takes an insightful turn as Dr. Kotlar delves into the complex realm of discounts in cash practices. He demystifies the restrictions and allowances surrounding discounts, providing practitioners with a clearer understanding of how to navigate this aspect successfully. The final focus of our discussion centers on distinguishing between medically necessary care and maintenance or wellness care in cash practices. Dr. Kotlar outlines the importance of accurately coding services based on the nature of the patient’s visit, offering practical guidance for maintaining compliance and avoiding pitfalls. Conclusion: As our enlightening conversation with Dr. Marty Kotlar concludes, chiropractors and practitioners in allied fields gain a wealth of knowledge to enhance their billing and coding practices. Dr. Kotlar’s expertise and insights serve as a compass, guiding practitioners through the intricate landscape of compliance, reimbursement optimization, and ethical considerations. In the ever-evolving field of chiropractic care, staying informed and proactive is key, and Dr. Kotlar’s wisdom provides a valuable roadmap for success. Stay tuned for Part 2 of this conversation to be released next week! Experience the entire episode by viewing it through: https://bit.ly/3U5sACL
