Picture yourself navigating a winding mountain road when, suddenly, rocks cascade down from both sides. That sensation closely mirrors what healthcare providers and companies experience when a federal or civil court decision lands on the Office of Inspector General (OIG) website. These decisions relate to more than 75% of healthcare compliance issues, often concerning coding and billing practices.
A couple of years ago, we evaluated our organization’s coding and billing procedures and introduced a “pre-billing audit” process. Initially, physicians resisted, fearing it would impact cash flow. They were right. We discovered we lacked the necessary human resources and streamlined processes for timely claims filing, resulting in up to twelve-week backlogs. However, we persisted, with top management’s active engagement and support, including the Board of Directors.
Top management’s involvement was pivotal in identifying bottlenecks: the shortage of human resources, inadequate training, and the absence of a monitoring and evaluation system for coding and billing processes. We recognized the value of an internal compliance coding team and IT database or software.
Our definition of the pre-billing process is auditing progress notes before generating a claim – think “getting it right the first time.” Re-coding and re-billing after the bill is sent out often raises auditing red flags. If coders spot missing information, they flag the case as deficient, delaying final billing until the provider provides clarification. This also applies to cases where coders believe there’s sufficient information for a higher level of service. Ideally, having a secondary layer of coding auditors for quality assurance is crucial.
Overcoding or undercoding are bad practices in the coding and billing world. Of course, you don’t want to hold these cases forever, since that impacts the revenue cycle. That’s another reason for the Medical Company to create a series of policies and procedures that:
- Describe the process and workflow
- Outline exactly how long to hold a case before final coding and billing
- Define who is responsible for query follow-up
- Describe exactly what to do (and what the next step is) if the provider doesn’t respond
- Educate coders, billers, and providers
- Provide feedback to providers and coders
- Describe how it will monitor, evaluate, and measure the accuracy of coders and billers
Facilitating the education of evaluation and management and ICD coding guidelines for coders and providers is the key to success in this process. Continuous internal and external audits to corroborate coding accuracy should be part of the compliance program. This system includes large investments in IT and Human resources, but I believe it is always worth it… It is, without doubt, a safety net.
