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BBT Ep. 4: Undercoding Leads To Lost Revenue

April 27, 202322 min read

In this episode we discuss an NPR article where a mother was caught by surprise with a six-figure medical bill. We also discuss in this episode how providers are undercoding which leads to uncollected revenue.

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Welcome to Better Billing Today, where we talk about all things billing. If you're involved in charging customers, members, patient billing, collections, customer support, PCI compliance, HIPAA payment technology, this is the podcast for you today. We have producer Chris on the controls as our guest. Welcome to the show.

Hello. Hello. Thank you for setting this up for us.

Surprise Six-Figure Hospital Bill

Today we're gonna go over a news article from NPR that came out on February 28th this year. And it is highlighting a loophole in medical billing and provider relationships and with their insurance companies.

Most of the time we have in-network rates, we have out of network rates, pre-determined negotiated rates that providers are allowed to charge the patients for the services. And then there's this gray area right between in-network and out of network, and that is called participating provider. And so these are also predetermined rates.

But the interesting thing about this is that these are higher than in-network. Rates but lower than out of network rates. And this is that gray area, that middle area that patients don't always know about and they don't always ask because the general question patients ask are, is this provider in network?

No. Is this provider out of network? No. If they ask the question, is the provider out of network? And they say, no. Most of the time, they're going to assume that the provider is in network and they don't know to ask this third question, which is, am I getting services from a participating provider?

Because while the prices may be lower than out of network, they may be so much higher than in-network, but they're not out of network prices. But it can feel like it's the same thing. So you have this person this family in, I guess it was Washington, that for some reason or another they had complications with the pregnancy.

We had the links to this article in the show notes, and long story short, this is a six figure. Hospital bill and the questions somewhere along the way between the moment this person was admitted to the hospital and stayed 56 days and had a baby somewhere in that stay, there wasn't any communication to the patient or it appears that there wasn't enough communication based on her response about the surprise of this bill.

This article just reminds us that while this isn't a podcast directed towards consumers as medical professionals and billing professionals and revenue managers, we need to be proactive in these conversations with the patients and let them know transparently that this is not that out of network, they're not in network, but we're a participating provider. Here are the rates that you're gonna pay for these services and you need to talk to your insurance company. If you can have those productive conversations, those proactive conversations with your patients, again, our target for this podcast is to help revenue managers create a positive patient financial experience and usher them through.

And educate them along the way, especially when you have such a long cycle. If it's just one visit for a chiropractor, they can have that conversation in five minutes. But if you're gonna offer extended care for a patient, these bills are gonna be high enough that you're gonna have to have that conversation and be proactive with that patient because they need to make an educated decision once they're stable, once they're able to move.

To a provider that is in their network, if that's what they want to do, they should have the information in front of them to make that decision. And from the article and the way it's written and what the patient says, doesn't sound like that's what happened, that they were caught by surprise. And had they been given the information up front, they wouldn't have stayed as long.

And you gotta wonder like who. Where's the patient advocate? The patient financial advocate wandering the halls in this hospital asking, do you have everything you need? Do you know what our rates are? Do you know that this is an out of. Not really out of network, but a participating provider and then explaining what that means and making sure the patient has better questions to ask their insurance company.

And it wasn't like she was uneducated about the process necessarily. She's a registered nurse herself. That's true. Yeah. She worked. In the healthcare system, and she knows that that not everything is gonna be black and white in network and out of network. But obviously when you're in a situation like this where the care of your unborn child and the care of yourself, those become first priority.

But even an educated healthcare worker is still caught off guard by this participating provider relationship and gets a bill that they're not expecting. And that's surprising. And imagine, who's gonna be experiencing something similar when they're not a healthcare professional. Just the average American walking into a hospital because, the transition, this article covers it.

The doctor was in network and he was a, an in-network provider. He recommended this participating provider. And I think the assumption is that why would my in-network. Provider recommends somebody out of network. He didn't recommend somebody that was out of network. And so again, there's this gray area that unless you really know what you're looking for and you're not versed in insurance and medical billing you may not know what questions to ask, but it's interesting to, it's an interesting article and I wonder how Swedish Medical Center is responding to this internally. What did we do wrong? They should be asking that question, what did we do wrong? What did we not do? Because we've gotta take better responsibility for the patient financial experience.

We've gotta make sure that we're being proactive in these conversations, giving written material. At the time of visit the weird loophole here was they didn't come through the emergency room, they didn't come through the emergency room. However, they did have an emergency!

They just came from their in-network provider directly to extended care. And because she was a registered nurse, she knew how to take the fight so to speak on paper.

Yeah. And thankfully she ended up getting this resolved. But if you don't have that net, that healthcare experience, and you don't know how to navigate these issues I'd hate to think what would happen to a, an average person who's not a healthcare professional.

Being referred to an participating provider but didn't come through the right door. Literally. We're talking about a box The door. A wall, yes. With a hole in it. And if you don't walk through that door, your bill is gonna be six figures point. If you walk through this door with these doors, but they have red letters on them that says, emergency, we're gonna waive this fee.

And it's just, it's another, this kind of goes into the topic of the week where it's another. Stamp of reminding you that insurance companies don't care about you. Insurance companies are public. Wait they don't. Insurance companies are publicly traded companies with shareholders and I'll put the link in the show notes, but there was $125 Billion uncollected in 2021 for healthcare providers, uncollected revenue.

Because the insurance companies don't want the providers to get paid, but they do want the consumer, the patient to pay as much as possible. And they are this evil middleman, I'm gonna say it out loud. They are the evil middleman between the provider and the patient.

And imagine start, you've gotta love what you do if you're a doctor. Because you genuinely have to love the patient in order to put up with this. Imagine being a capitalist and starting a business and saying, I'm gonna go serve my customers, but my customers can't pay me. The insurance companies have to pay me and it'll take me 90 days to get paid. I have to hire somebody with years of experience learning complicated codes, and if I put the wrong code in.

I don't get paid as a capitalist. You would never enter that business without a really strong plan on how to overcome this. Yeah. If you're a provider and you genuinely have a care for the human body and the human race, and you want to pro to help people, you're gonna go into this business. Not to just get rich, but to really make a difference in someone's life.

So you have this. Really capitalist driven, and I love capitalism, but you have this money hungry company over here that's just serving shareholders and board members, crony capitalist insurance company partnered with this benevolent healer (which is a weird combination in my opinion).

And then you have these poor consumers, patients that come in for basic services and they get these surprise. I'm not saying that this particular example is basic service, but in general you're getting services that are very people have babies every day. That's true. Having a child is pretty common.

But I just mean that services. Seems simple to the patient. But yet should be simple. It's mired in this complicated gobbly gook of codes. Red tape. Red tape Bureaucracy, because there's only one reason for this. Insurance companies want to charge. The patients as much as possible, pay out as little as possible and pay themselves in the shareholders.

So that's the game we're playing. How can I efficiently learn the codes that need to be learned so that I can enter these codes? If I don't enter these codes correctly? I don't get paid. If the patient doesn't come through the right door, they're gonna overpay. So the insurance company has two, two goals here.

Make it tricky for the patient so they don't understand their bill. Make it tricky for the provider so they don't have to get paid. And you're saying that providers under code? Oh, absolutely. So much. And that's where a lot of the revenue is being lost? Yeah. The we've said it on the show before that the number one expense a provider has is uncollected revenue.

In 2021, there was 125 billion. Uncollected meaning we didn't put the right codes on this form, and the insurance companies aren't gonna help us fix it, right? They're going to pay out what you've requested. If it's in their benefit. If it's in their benefit, they're gonna pay you less. But if it's not in their benefit, they're not gonna pay you more, obviously.

So you have 125 billion uncollected. And that is gonna be felt by providers, their staff, their vendors, right? This is a trickle down effect where everybody loses when somebody's undercoding. A service and giving it to the insurance companies. So the insurance companies wanna make sure that patients get these surprise bills and pay them.

Hopefully they just pay them without question. Thankfully on this six figure bill this one got forgiven. And it wasn't the insurance company that forgave it. It was Swedish Medical. Swedish Medical because. It's interesting that they're the ones that said, we're gonna zero this out because you came through a different door.

But honestly, they didn't have this conversation with them and it should never have even gotten this far where the patient got this built. You know this starts the moment the patient walks in the door when they're stable, you have a conversation with them. You talk about transparent pricing. So thankfully they zeroed out this bill and the patient isn't gonna have to pay this six figures.

But it should never have even gotten that far, honestly. If you look at the steps of the process there was just, it looks like there were steps that were skipped and it, that's really just unfortunate that they even had to go through that experience. It's like negligence. Yeah, it's negligence.

It's someone not being proactive and having a clear conversation with that patient. But I wish there was more in the article. Obviously they can't talk about too much, but I wish there was more in the article about the reasons the exact reasons why the bill got created and why it was zeroed out, but so how are patients supposed to know these types of things if they're not registered nurses themselves?

Yeah, it's a good point. If you're not. Versed in the healthcare system. How do you know to take that unjust bill from six figures down to zero? I think most people are gonna take a legal route and fight it in court, which costs time and money. And who knows what tactics the insurance company would've taken to defend that bill if Swedish didn't step up and zero this out.

And then who do you fight? The patient doesn't know who to fight, so they're gonna they're gonna have to consult an attorney to figure out how to get out of this bill. Or maybe they take the the slow pay route. Okay? I'll pay you $10 a month till I die.

That's one method that you could take, but it's. It's not recommended. Who wants to deal with that? Who wants to deal with that for 20 years? Yeah. So especially when it's something as gray as participating provider. Oh, for sure. Yeah. It seems if you're going to take on patients as a as an insured and the insurance company should do more education for their patients and they're not going to, it's not in their best interest.

It's not in their best interest again, Crony insurance companies, making things difficult for patients and providers since 1982. That should be their slogan. So speaking of providers, how are you know, they supposed to stay up to date with all of these codes. They change all the time.

You've got overcoding, undercoding, all of this improper coding. And you said earlier that undercoding is where all of that revenue gets lost. That's rightfully owed to them and it's uncollected. Yeah, unfortunately, it just comes down to staying on top of it. And they're, the insurance companies are making the services difficult to code, and they're making it difficult to get paid.

So they're, you have to depend on a human. And now we do have some really great software that's out there that will help us collect more. But how many of the average. Providers are going to invest in that billing system that will catch these errors. You have the CPT codes that identify the services rendered, right?

Then you have the ICD 10 codes, which represents the patient diagnosis. And if you don't get both of these right, and you're not coding exactly what you need to, you're not gonna get paid what you should. So you're depending on a human to know these codes to code properly. And if you're a provider, You don't have time to go to the office and make sure that your medical billing specialist is really doing their job correctly, unless there's a feedback loop of internal controls that is monitoring this like a medical billing company would if you're not investing in a, in an audit for your own internal billing.

You are going to have errors in your billing, right? The doctor can't always be hovering over and double checking work. No, absolutely not. It doesn't make sense if a revenue manager is a professional that can check CPT codes ICD10 codes and do a reconciliation and pull the charts and make sure that we are getting all of our bills out to the insurance companies with the right codes on them because, That revenue manager's job is to make sure that we are, there's they have a few goals.

Patient financial experience. Transparency, communication, being proactive. Customer support, customer service patients, patient support, but also, Making sure that the staff is billing correctly. If they under code the biggest one. The, you mean that's a big deal. Undercoding is gonna cost you a lot more than hiring another professional to do medical billing.

You have a leaky ship.

Absolutely. So you're just leaking money and you don't even know it. So investing in, in, I think for a provider to answer your question, investing in competent leaders that. Have a demonstrated track record of understanding the changes in the industry, the complexities of the insurance company, the most recent changes to HIPAA laws and coding.

That's a lot to keep up with. But that's why they're professionals and they get paid well to do their job because they keep the money coming in. And they make sure that the patient is not caught off guard, that they understand their bill, that they know what their options are.

And they know that the bill is correct based on what was the services rendered. Everything becomes clear. Yeah. Revenue managers have a job of from the top down providing clarity. For provider, for patients and managing the insurance companies to make sure they get paid what they're supposed to, and that, that's exactly what Spark does.

Yeah, spark billing services, a medical billing service company. We're gonna do that for the small practice. We're gonna do that for the office with two or three providers that doesn't have a big investment in their revenue management cycle. They have and not to. Not to play down small business, cuz we've, I've been there, I've had one bookkeeper and they weren't the best.

But they were what I could afford at the time. And then we grew to what we have now. But these smaller offices sometimes have somebody who's part-time, maybe a relative, maybe somebody who's actually retired and actually isn't trying to keep up with the industry standards and doesn't have the patience to deal with the insurance companies.

And they're really just doing this part-time to stay busy or help a friend who's a doctor. Labor of love. Yeah, labor of love. There's a lot of different motivations for why you might hire somebody to do some billing. But as soon as you approach your medical billing with just some billing attitude, you are cutting your own lifeline because your revenue, your salary depends on this.

And also, more importantly, the patient financial experience. This is even though we need money to operate, if you provide great care for your patient in the service, but then they have a poor experience. With your billing specialist, that's gonna be enough reason for them to go find a new provider.

Yeah, they're gonna go to Dr. Smith instead of Dr. Johnson.

So you have two reasons for a lack of money in your pr, in your office, you have lack of understanding of medical billing. Navigating the insurance companies rules and regulations and red tape, and then you have bad customer service around the billing experience.

And those are two of the biggest reasons why a provider might have cash flow problems. Which is, I'm not coding correctly, and even if I am, I'm not giving. Good financial experiences to my patient. They could have amazing bedside manner and taking really good care of their patients, in, the meeting room.

But when they get that bill or if they get the bill, sure. Yeah. You can have great bedside manner as a provider. But if the patient has problems with their billing, either it's too high, it's incorrect, or they're not getting good patient support by the billing specialist. If you don't have somebody who's hired and paid to answer questions and explain the bill, cuz your billing specialist says, I've got bills to code, I've got, benefits to report. I've got reconciliation, I've got work to do. How many of our billing specialists are being asked to also turn on their customer service hat and explain a bill to somebody or put together a payment plan. But if you can separate these duties like a medical billing company does, or you have somebody whose only job is to make sure that the bills are put in correctly, that we're batching these.

We're sending these off to the clearing house every single day, and then you have somebody whose only job is to help with patients and explain bills and create a positive patient financial experience. Then you have a really seamless process where bedside manners are good, the patient billing is accurate.

The patient understands their bill, they know what their options are, and they feel like, wow, I'm really being cared for, not just because of the ill that I had, but all the way through my financial pain. You've got physical pain, financial pain. If you can care for that patient throughout the entire process, you're gonna have a better, obviously better reviews, but you're gonna feel better as a provider because you're not just sending them off to the financial slaughtered house, if you will, to just fend for themselves.

"Hey, I took care of your back. I took care of your blood work. I took care of you. Okay. You're on your own when it comes to the finance side." That's an experience that will lead them to find another provider, unfortunately. And that's why there's two big reasons that providers have cash flow problems.

They don't know how to bill, or they don't know how to take care of their patient on the billing side. It sounds like you're talking about a. Sort of synergy between specialists who know how to bill and code correctly. And other people who know how to take care of that patient and break down and give clarity to what they're being billed for.

Abs absolutely. Customer service and patient. Support those things are almost equally as important because they actually involve other members of the family. So you have maybe a mother or a father or a child getting care, but then the family as a unit is sometimes dealing with the patient billing side.

And so you have one patient who needs services, great, let's get them patched up, let's get them supported. But then you're impacting. And sometimes that can be a quick event, right? This can be less than a few months, maybe a few weeks, maybe even a day. But then the billing side can take six months to a year, depending on how large the bill is, depending on how complicated the insurance companies make it.

This can be a multi-month, multi-person layered process just for your kid getting their tonsils out. It's not that bad sometimes, but I'm just saying if you have, depending on the service that they're getting, If we just focus on the service, we're miss missing almost, I think 60 to 70% of the equation.

Service is just only 30% of what the patient is going to experience. But this also backs into the moment they arrive. How are they greeted? How is the paperwork being done? Are they communicated to throughout the entire process what the procedures are going to be? What the, if they know And just preparing them for the financial experience after the service.

So it just takes a lot of thoughtfulness and a lot of care. Yeah. To give a patient a really great experience and their family who's might be pitching in to pay this. If you're a middle-aged person taking care of aging parents, Or if you're taking care of kids you're gonna have second tertiary people involved in this. And so it's important to educate your billing specialist if they have the bandwidth to do customer support, how customer service works. So you have service billing, technical. And customer service, which is social, personal, but it's also, you gotta, you have to follow HIPAA laws and make sure you're not disclosing information you can't discuss and, the way you leave voicemails.

It said, follow up and talk to me, but I can't tell you what it's about. Yeah. So it's customer service, it's technical billing. It's also medical knowledge of patient care. It's quite a topic, which is why we have a podcast on this to discuss these things and take your phone calls and take your emails.

Where can they send in their email questions and where can they send us messages to, to discuss these topics to help improve the industry? Our, one of our main purposes for this podcast is that a rising tide raises all ships. If we can make the medical billing industry better and just contribute to this.

This transformation that's happening in the industry with revenue managers taking these responsibilities and really trying to focus on the patient financial experience. We want to contribute to that conversation. We want to be involved in that transformation. So how can we get people who are interested in this topic to either ask questions, join us on the show, be a guest.

Or suggest a topic that we cover? Sure. They can reach us at office at Better billing today. They can go to our and they can see all of our previous episodes, blogs, podcasts, and find us on their favorite podcast platform and subscribe there. That's right. You just showed me yesterday that we're also on Spotify, our iHeartRadio Radio Public Pandora, Stitcher, Amazon, YouTube, and coming to Apple Podcasts soon.

Google and Apple podcasts. Yeah. That's great. So whatever platform they like to listen to this on this will be there for them. And we have plenty of resources in the links. If you are a revenue manager or you're a provider and you want some of the resources we're passing out how to find uncollected revenue, how to increase the quality of the patient financial experience from the moment they walk in the door to the moment they pay their last bill.

We have some of those resources for you in the show notes We'll be here next week covering all of the topics related to patient billing, HIPAA, technology, medical billing, and anything in the industry that will help you become a better revenue manager.

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