In a recent ICD-10 Monitor article, Bonnie Cassidy, vice president of consulting for Precyse MedAssets, claimed that the best way to get a handle on the growing number of denials under ICD-10 is for various players along the revenue cycle to “work collaboratively to design and deploy … a new pre-bill review process.”
“Long gone are the days of releasing a claim as fast as you can without regard to the clinical documentation integrity (or lack thereof) impacting future denials,” Cassidy wrote.
The Overpayment Problem
She also cited the new Medicare 60-day overpayment rule, which requires that an overpayment must be reported and returned by 60 days after the date on which the overpayment was identified “through the exercise of reasonable diligence.”
According to Cassidy, a “pre-bill review process” not only reduces overpayments through proper billing, but it also offers insight into how to conduct “reasonable diligence” to identify overpayments.
“Technology-enabled, pre-bill clinical documentation integrity and coding review, coupled with a CDI and coding component supported with an approved revenue cycle bill hold, will represent a critical component needed to allow providers to be successful for this new Medicare program,” Cassidy writes.
An Expansive Review Process
In addition, because overpayments often are generated in the following circumstances, an expanded pre-bill review process could identify the following scenarios and flag them for resolution prior to a claims submission:
- Non-covered services
- Duplicate payments
- Billing Medicare first when another payer is primary
- Wrong place of service
- Wrong provider
As well, many other scenarios create denials or delays that could be remedied prior to submitting a claim through the pre-bill review process, such as with an electronic claims scrubber:
- Correct Coding Initiative Edits
- Code/Gender mismatch
- Missing modifiers
- Medical Necessity
Post-Bill Reviews Help, Too
Of course regular clinical documentation reviews to assure proper documentation of coded and billed procedures also should play a critical role in your post-billing review process. Along with reporting back to physicians and other clinicians with ways they can improve their documentation.
Most payers, especially government payers, have audit and review processes in place to detect overpayments and billing errors. You can proactively address the timely and costly process of identifying and filing appeals and overpayments by implementing your own audit and review process before a claim ever leaves your practice management system.
For more information about how CIPROMS can implement a pre-bill review process on your behalf, contact us today.
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