Best Practices to Avoid Improper Billing

Billing may be a meticulous process, but sometimes things fall through the cracks.

There’s a long process of medical coding, communicating with payers, and the back and forth of claim denials and appeals before a medical bill reaches a patient. Despite the most meticulous efforts, mistakes are still made.

Recently, Penn State Health voluntarily disclosed that from December 2015 to November 2022, it had submitted claims to Medicare for annual wellness visits that were not supported by medical record. According to a release from the United States Attorney’s Office, the system “took prompt corrective action,” the issue was discovered and has agreed to pay over $11 million.

Similarly, in California, Pomona Valley Hospital Medical Center voluntarily disclosed that from December 2016 through September 2021, it overbilled Medi-Cal for prescription drugs and have agreed to pay over $2 million.

Here are some best practices to avoid improper billing:

Payer strategies

Payer relations was a main topic at HealthLeaders’ 2023 RevTech Exchange, with leaders sharing solutions and insights for alleviating the strain of denials. Jonathan Benton, assistant vice president of Atrium Health, offered the following recommendations to attendees:

• Prioritization: use algorithms to score priority based on an accounts likelihood of being recovered or being denied
• Automation: automate tasks to reduce work burden on staff and speed up operations
• Cultivation: organize work to maximize system automated priority, embedding daily behaviors and techniques
• Analysis: keep track of factors impacting key performance indicators
• Resilience: Inundate payers with appeals and follow up on automated denial responses

Price transparency

In a previous HealthLeaders story, we mentioned the results of a Patient’s Rights Advocate poll, where 93% of respondent believed hospitals should be required to share the prices—not estimates—for planned care in advance. Individual providers and health systems alike have struggled to adhere to the No Surprises Act and Lower Costs, More Transparency Act, but Tina Barsallo, vice president of revenue cycle operations at Lifepoint Health, believes that collaborating with peers can help with these efforts.

“If possible, pull a team together to create joint ownership and partnership in creation of the tools and to help drive consistency and compliance,” she previously told HealthLeaders.

Lean on your patient portal

Patient communications are now mostly facilitated through a patient’s preferred method, whether it’s by phone, email, text, or messaging via a patient portal. Many portals have capabilities that allow patients to review as well as pay their bills.

However, to ensure patients regularly access and utilize their patient portal, it must be accessible and easy to use.

When the Ann & Robert H. Lurie Children’s Hospital in Chicago began strategizing ways to increase patient portal utilization, it launched the Every Patient, Every Time initiative where at every interaction with a point-of-service staff member, each patient was offered portal access.

“What we found was just purely telling them about it…was enough to get them activated,” Ravi Patel, the hospital’s vice president of digital health, previously told HealthLeaders.