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When it comes to medical coding and billing, accuracy is everything. Even the smallest error can result in a claim being bounced back by the payer, causing delays and missed revenue opportunities. Coding requirements change frequently, and with denials totaling billions of dollars per year, providers can’t afford to risk under- or over-coding or relying on outdated codes. Automation and software-driven solutions can uncomplicate the complex world of medical coding. Getting claims right the first time accelerates the adjudication process, leading to faster and higher reimbursements. Providers can make more reliable financial forecasts, avoid losing time reworking rejected claims, and give patients greater clarity about what they’ll owe. For this reason, providers should brush up on medical coding and billing best practices to improve claims management and maximize reimbursements. Here are 7 areas to focus on: 1. Stay up-to-date with coding changes Medical codes convert information about the patient’s healthcare encounter into an electronic format that payers use to adjudicate claims for reimbursement. If a claim includes outdated, incorrect or missing codes, then it will be denied. The most common medical coding systems include: International Classification of Disease 10th edition (ICD-10) codes: these codes denote the patient’s diagnosis or condition. The 11th version was published in January 2022, and while the implementation timeline in the US remains unclear, providers will need to be ready to adapt. Current Procedural Terminology (CPT) codes: Where ICD codes describe the patient’s symptoms, CPT codes record their treatment. If there’s a discrepancy between diagnosis and treatment, the claim is likely to be denied. Healthcare Common Procedure Coding System (HCPCS) codes: the Centers for Medicare and Medicaid Services (CMS) use these to apply CPT codes to procedures, services, products and equipment offered to Medicaid and Medicare patients and those covered by private insurance. These codes are constantly being revised and are often recycled, so coders must pay close attention to avoid errors. National Drug Code (NDC): claims need to include NDC codes when the patient is taking prescribed or over-the-counter medications. The NDC directory is updated daily. Diagnosis-Related Group (DRG) codes: these combine ICD and CPT codes to determine the final amount that a hospital can be reimbursed. CMS assigns annually calculated weightings to DRGs based on severity and length of illness, treatment trends and other factors. There are also multiple coding directories for different specialties, such as dental care, mental health and patients with disabilities. With hundreds of thousands of constantly-changing codable terms to consider, medical coders face a daunting task. In the past, coders would rely on manual coding directories to find the right codes, but today, most use digital encoders and digital coding libraries to generate electronic codes. For example, Experian Health’s claims management software integrates government and payer edits so that no changes to coding requirements are missed. Each patient encounter can be processed in real time and incorrect codes can be flagged before the claim is submitted. 2. Automate the claims management process to increase medical billing and coding accuracy Manually matching each patient encounter to a specific set of codes is time-consuming and vulnerable to errors. Software programs improve the process by analyzing unstructured clinical charts and notes to draw out information relevant to the claim. They can cross-reference multiple coding directories in an instant to identify the correct code. They also compile data in standardized, interoperable formats so information can be exchanged between coding and billing teams, clearinghouse staff and payer systems with ease. While some of the output generated by machine learning systems still needs to be checked by human eyes, automated solutions drastically reduce the burden on staff and ensure greater accuracy. With automated claims management, medical coding and billing teams can optimize their workflows, submit cleaner claims, and get insights into the root causes of denials. Case study: see how Summit Medical Group Oregon – Bend Memorial Clinic used automated claims management technology to achieve a primary clean claims rate of 92%. 3. Eliminate workflow inefficiencies to save time According to the Council for Affordable Quality Healthcare (CAQH), automation could save more than an hour of staff time for every three claim status checks. Automation frees up staff to focus on the highest priority tasks that require a human touch. Fewer errors mean less time spent on reworking denied claims. And if claims are processed more quickly, this means that they reach the payer adjudication stage sooner which ultimately will result in faster payments. The medical coding and billing process takes anywhere from a week to a few months, so every hour saved makes a difference. To this end, Enhanced Claim Status monitors how claims are progressing through the claims adjudication process, reducing the amount of time staff need to spend interacting with payers. It eliminates manual follow-up and allows teams to address pending, returned, denied and zero-pay transactions before the Electronic Remittance Advice and Explanation of Benefits are processed. Worklists are generated based on actionable data so staff can work more productively, and claims get settled sooner. 4. Customize claims edits to your specifications One way to drive up medical coding accuracy is to use customized claims edits. Some claims management software solutions only apply updates using universal claim edits or using groups of edits. This doesn’t work for large medical groups that need to cover multiple combinations of payer, specialty and geographical edits. Since no two payer policies are the same, claims edits would need to be checked manually to make sure nothing has been missed. Experian Health’s claims management software solves this by incorporating government and commercial edits alongside client-specific customized edits. Providers can keep pace with changes and capture the requirements of all reimbursement policies that are relevant to a particular claim. For example, ClaimSource runs front-end claims editing to coordinate federal, state and commercial payer edits together with customized provider edits to avoid coding errors. Similarly, ClaimScrubber automatically reviews and adjusts claims, helping medical groups streamline claims submissions. 5. Upgrade record-keeping technology to maintain medical billing and coding accuracy If patient records are peppered with typos and outdated contact information, then it’s highly likely that errors will be inherited on claims forms. A fifth of patients have spotted errors in their health records, including incorrect details about diagnoses, medications and test results. Preventing these errors is key to maintaining medical billing and coding accuracy. Interoperable electronic patient records protect against inaccuracies by creating a single, complete record for each patient. With a tool such as Universal Identity Manager, patient data is matched against multiple data sources to verify that the record is complete and accurate. Staff can have confidence that all information held on a patient will be taken into account when their medical encounters are coded, and avoid coding discrepancies that can occur when a patient’s treatment doesn’t seem to match their diagnosis. 6. Double-check claims before submitting  Running a line-by-line review of each claim before it’s submitted means errors can be found and fixed before they result in financial losses. This would be a painstaking task to do by hand, but with tools such as ClaimSource and ClaimScrubber, hospitals and medical groups can audit claims automatically to check for coding discrepancies or missing patient information. A streamlined claims cycle benefits payers and patients too. Payers can adjudicate accurately coded claims more quickly without pushing them into a queue for manual review, and patients get earlier clarity about how much they’ll owe. 7. Audit the claims management process to spot medical coding inaccuracies Finally, it makes sense to undertake regular audits of the medical coding and billing procedures to weed out any recurring issues. While a coding audit will focus on coding accuracy and compliance, a billing audit can investigate the systems and processes involved in everything from patient eligibility verification to patient collections. This helps uncover recurring issues with under- and over-coding, use of redundant and retired codes, non-compliance and poor documentation. Again, maintaining robust, quality data and records will make this process easier. Partnering with a single, trusted vendor to deliver an end-to-end claims management solution can help achieve this. Find out more about how Experian Health’s automated claims management solutions can help healthcare organizations maintain medical billing and coding accuracy, drive down denials and create a more predictable revenue cycle.

Paying for healthcare has long been a complex experience for patients. Inflation means more families are tightening their wallets, so the demand for clarity and flexibility is increasing. At the same time, the pandemic’s digital legacy means patients have had a taste of contactless and online payment methods – and they want more. This means that providers will have to focus on creating a better patient payment experience. Could a modern financial experience that benefits patients and providers finally become the norm? Experian Health President Tom Cox addresses this question in a recent PYMNTS publication of healthcare leaders’ predictions for the second half of 2022. Concerns about economic uncertainty, along with a desire for more financial predictability, means that providers can benefit from delivering a better patient payment experience. How? These 3 emerging trends could guide the way: 1. Patients expect a frictionless payments experience As patients bear more financial responsibility, they expect paying for healthcare to be as easy as buying a new sweater. Experian Health and PYMNTS data found that one-quarter of consumers used digital methods to pay for their most recent healthcare visits, with patient portals being the most common at 14%. Contactless and mobile payments are also becoming more popular. To eliminate friction, providers must start by identifying the pain points in their payment processes. Do patients know in advance how much their bills will be? Are they given advice and options to spread out payments if they can’t afford to pay the entire bill in one shot? When it comes time to pay, can they find a familiar and convenient payment method? Providers that can answer yes to these questions will have the edge when it comes to delivering a satisfying patient payment experience. When it takes an average of more than 30 days for providers to get paid, any strategies to make it easier for patients to pay sooner and in full will help provider cash flow. Offering quick and convenient digital payment methods that patients can access anywhere, pre-and post-service, will be the key to delivering a better patient payment experience and accelerating collections. 2. Amidst concerns about cost, patients want transparent pricing New research by Experian Health and PYMNTS found that consumers who were under financial pressure were more likely to cancel appointments out of concerns about costs. More than 2 in 5 patients who received inaccurate estimates ended up spending more on healthcare than they could afford. It’s no wonder that 6 in 10 patients who received an unexpected bill or inaccurate estimate say they would switch healthcare providers for a better experience. Cox notes that alongside consumer demand for a better patient payment experience, regulatory change is giving providers a further nudge toward price transparency: “The Hospital Price Transparency Final Rule and the No Surprises Act have put accurate data at the forefront of efforts to transform the patient’s financial experience. Together, these regulations can create the same pricing experience that consumers enjoy in other verticals, namely knowing the cost before making a purchase.” To date, implementation has been patchy. In August 2022, only 16% of hospitals were found to be compliant with the federal price transparency rule. In a recent conversation with Healthcare Finance News, Experian Health’s Chief Commercial Officer, Jason Considine, acknowledges that providing accurate estimates takes work: “Getting these estimates involves having information about the patient's benefits and insurance plan to create an accurate estimate… On top of mind for most provider organizations is an expectation of spending to increase for technology as regulations expand.” Investing in the right technology can help providers deliver financial clarity to patients. For example, Patient Estimates is a web-based price transparency tool that generates accurate estimates for patients before and at the point of service. It can also direct patients to payment plans and charity care, to help them plan and spread out the cost of care. Similarly, Patient Financial Advisor gives patients a pre-service estimate of their expected financial responsibility delivered straight to their mobile devices, and offers methods to make a secure payment. 3. Digitalized patient payments require better data and analytics Maximizing the impact of the above strategies relies on having the right data and technology in place. For example, in Accessing Healthcare: Easing Digital Frictions in the Patient Journey, Experian and PYMNTS found that patients may pay in person most often, but at least a quarter would prefer to pay online. Some may want to pay in full while others want to spread the cost. How can providers tailor their approach if they don’t know which patients want which option? Considine says that “Providers have to figure out the right financial pathway. It takes leveraging data to know the right financial experience." Achieving this requires a combination of consumer data, financial information and demographic details to create a complete picture of each patient’s needs and preferences. Patient Financial Clearance leverages Experian’s unrivaled datasets to calculate an optimal payment plan for each patient, based on their unique situation. Patients are guided to the right plan, giving them a sense of confidence about what to expect. It automatically screens those who can afford to pay upfront and those who may need more time. It’s a more supportive experience for patients and increases point-of-service collections for providers. Another option is PatientSimple®, which identifies the optimal financial pathway for consumers and makes that pathway available through its consumer-friendly, mobile-compatible, self-service portal. In short, patients want better payment methods, upfront price estimates and personalized payment plans. Data and technology can bring these to life. Find out more about how Experian Health can help healthcare organizations deliver a payments experience that meets and exceeds patient expectations, complies with regulatory change, and accelerates collections to help providers ride out financial uncertainty.

Does a patient’s age influence their experiences with rising healthcare costs? A recent report from Experian Health and PYMNTS points to a generational gap when it comes to the impact of and responses to medical bills. The study takes a deep dive into how Gen Z, millennials, Gen X and seniors are reacting to the growing cost of care. From canceling appointments to being surprised by out-of-pocket expenses, this article looks at the key differences in generations and healthcare costs, and the tools and solutions providers can implement to support their patients. Millennials are most likely to cancel appointments due to high-cost estimates A worrying proportion of patients are choosing to delay or forego care because of concerns about cost. This seems to be felt most acutely among younger patients. According to the new data, 74% of millennials and 56% of Gen Z patients have canceled a healthcare appointment after receiving a cost estimate that was higher than they could afford, compared to 13% of baby boomers and seniors. Gen X patients fell in the middle, with just over half canceling appointments after receiving high estimates. That said, healthcare costs affect all generations. While older patients seem less likely to cancel appointments due to cost, the “Medicare Effect” suggests that many hold off seeking care in the first place, until their costs are covered at age 65. Many households, regardless of demographic, are walking a financial tightrope as inflation continues to climb and patients bear responsibility for a greater portion of healthcare costs. Providers can help minimize the number of patients forgoing essential care by helping to track down any available coverage, so patients aren’t inadvertently billed for care that could have been covered by a forgotten health plan. Coverage Discovery continuously scans commercial and government coverage using multiple proprietary data repositories, advanced search heuristics, and machine learning matching algorithms. Finding missing coverage means upfront estimates will be more accurate, and patients will be likely to see a lower co-pay amount. In 2021, Coverage Discovery tracked down previously unknown billable coverage in more than 27.5% of self-pay accounts and found more than $66 billion in corresponding charges, removing a huge burden for patients and providers alike. Gen Z patients are most surprised by out-of-pocket expenses Overall, 19% of patients found they spent more on healthcare than they could afford in the last 12 months. As would be expected, those who received inaccurate estimates (43%) experienced more financial distress than those who received accurate estimates (26%). Among those who paid out-of-pocket expenses for their most recent healthcare visit, Gen Z patients were the least aware that they would be required to make a payment, with 32% not knowing that they’d need to make co-payments. Only 20% of Gen X and 10% of baby boomers and senior patients were unaware. One way to alleviate the strain of unexpected bills is to issue cost estimates automatically, before the patient’s visit. Only 34% of surveyed patients received estimates automatically before their visit, so it’s no surprise that many are caught unaware when the final bill arrives. With Patient Estimates, patients get a breakdown of their expected costs based on real-time provider and payer data. The estimates are delivered automatically to the patient’s mobile device (along with links to convenient payment methods. An earlier report by Experian Health and PYMNTS found that patient satisfaction rose by 10% when billing estimates were provided, underscoring their value. Millennials pay the highest out-of-pocket expenses Millennials appear to have been hardest hit by out-of-pocket bills. The average across all respondents was $363, but millennials paid an average of $619. This could explain why millennials were more likely to cancel appointments. Providers can help patients manage balance bills by providing tools that make it easier to plan and pay their bills. For example, Patient Financial Clearance screens and segments patients so providers can help guide them to the most suitable financial pathway. PatientSimple and Patient Financial Advisor help patients access cost estimates, identify best-fit payment plans, apply for financial assistance and make payments, via their patient portal or mobile device. Baby boomers and seniors are most satisfied with the healthcare payment process Most patients were generally satisfied with the payment process for their medical bills. Older patients appeared to be slightly more content, with 77% of baby boomers and seniors saying they were satisfied, compared to just under 70% of Gen X and millennial patients. Gen Z was the least satisfied, at 60%. With 22% of unsatisfied patients saying they’d consider switching providers, getting the payment experience right is high stakes for providers. So, how can providers improve the payment experience for those who are less than completely satisfied? Accurate estimates, tailored payment plans, clear communication and convenient payment methods will all be in the mix. For most healthcare organizations, this will mean embracing digital tools and automation. Experian Health’s State of Patient Access 2.0 survey revealed that while younger patients may be especially receptive to a digital patient payment experience, it crosses generational lines. Members of “Gen C” – digitally-connected consumers of all ages – are looking for a streamlined payment experience. When patient loyalty and decisions about when to receive care are so heavily influenced by the financial journey, it makes sense to offer digital estimates, billing and payments where possible. The good news for providers is that prioritizing patient satisfaction doesn’t mean sacrificing efficiency. Automation and digitalization can facilitate greater choice and convenience for patients, without requiring additional staff input. In fact, it’s likely to yield productivity gains and free up staff to focus on delivering an even better patient experience, and support patients to get the care they need. Find out more about how Experian Health’s suite of patient payment solutions can help providers deliver a financial experience that satisfies patients of all generations and healthcare costs.