Follow these performance metrics for successful Gastroenterology Billing

 Managing patients along with implementing effective reimbursement methods is something that every provider finds challenging. Similarly, gastroenterologists face several challenges in the reimbursement process that affect the financial growth of their practice. Gastroenterology billing consists of complex, high-volume endoscopic procedures, including colonoscopy and esophagogastroduodenoscopy (EGD).

The in-house GI billing team also needs to adhere to medical necessity for screening and diagnostic tests. They also need to ensure accurate use of modifiers, ICD-10 codes, and frequent prior authorization that is required for procedures like capsule endoscopy. To ensure all the components are effectively tracked, specific performance metrics play a critical role in managing the complexities of billing.

The key performance metrics in gastroenterology billing

The performance metrics, also known as key performance indicators (KPIs) in gastroenterology RCM act as benchmarks for billing accuracy, regulatory compliance, and reimbursement rates. Tracking these metrics will not only maximize your revenue generation but also improve revenue generation and patient care. The following are the major performance metrics required for gastrointestinal care billing:

1. Clean claim rates – The clean claim rate or first-pass ratio refers to the percentage of clean claims paid on the first submission. This rate helps to detect the total number of claims accepted on the first submission. To put it in simpler words, a claim is considered clean if it is submitted correctly on the first time, without errors or avoidable denials. Endoscopy billing uses this metric to reduce reimbursement delays and prevent expensive rework. It is recommended to have a clean claim rate (CCR) of 90-95% for a successful revenue generation.

2. Days in accounts receivable (AR) - The number of AR days represents the average time taken to receive reimbursement. Gastroenterology practices usually aim for an AR period between 30 and 40 days for optimal financial health. This period can be stretched up to 45 days in some cases. If the wait for reimbursement is long, providers tend to lose cash flow and the opportunity to invest. It is recommended to consider 30 days in AR for an uninterrupted reimbursement process. Any accounts receivable over 60 or 90 days are prone to high financial risks and require extensive follow-up.

3. Net and gross collection rates – It helps these metrics measure the total amount of allowed revenue that is collected. An efficient healthcare revenue cycle management will be able to reach 95% or higher net collection rate (NCR). These indicators represent the efficiency of the revenue cycle and are an important contributor to the financial stability of your practice.

The gross collection rate (GCR) represents the total payments divided by total charges. This acts as a preliminary indicator rather than a measure of true revenue efficiency. While NCRs of 95-99% are considered a standard for measuring actual revenue capture, the GCR falls in the range of 24-45%. This depends on the comparison between fee schedules and contracted payer rates. Digestive disease reimbursement methods often witness higher denial rates in comparison to other healthcare specialties. This can reduce overall collection efficiency without proper management.

4. Turnaround time for denial resolution – After claims are denied, the in-house billers need to work on them to ensure that they are resubmitted correctly. The turnaround time for claim resubmission is usually between 7 to 14 days. If the resolution rates are faster, it prevents the accumulation of pending AR follow-ups. Many high-performing gastroenterology clinics aim to rework and resubmit denied claims within 48 hours to 14 days. The quick resolution of claim denials within the first few weeks is crucial to prevent AR delays of over 45 days. This reduces the chances of reimbursement of the medical services offered to patients.

5. Point-of-service and patient collections – The point-of-service collection represents the percentage of patients’ responsibility captured upfront. This metric helps in reducing bad debts and improving cash flow. Some of the major metrics include validating expensive medical procedures (EGD, colonoscopy) with the help of prior authorization along with maintaining a clean claim rate of more than 95%. Monitoring a high percentage of denials for gastroenterology procedures requires close supervision of denial rates, ensuring that they are below 5%.

6. Bad debt rates – This represents the balances that are written off as uncollectible. The gastroenterology procedures are expensive, which means that a minor increase in bad debts will impact the reimbursement. The important ways to minimize bad debts include front-end insurance verification, transparent patient financial communication, and the application of automated RCM tools for faster follow-ups.

For healthcare clinics, it often becomes difficult to track performance metrics while providing healthcare services. Providers are involved in handling multiple billing challenges which makes it overwhelming for them to monitor the performance insights. This is where an outsourced company plays a key role in ensuring billing efficiency along with tracking the key performance indicators.

How outsourced companies sort the gastroenterology billing issues

The changing payer policies and updated coding regulations create hindrances in the way of coding. It often becomes overwhelming for in-house gastroenterology billing teams to stay aligned with the constant changes and work for effective reimbursement. Hiring a professional medical billing company will help to eliminate the challenges and minimize errors, leading to a successful GI practice. There are companies which offer a wide range of benefits including 30 days’ free trial, $7 an hour rates, no binding contracts, and dedicated account managers for every client. These RCM service providers have proven years of experience, come with trained billing staff and CPC-certified coders. They have the skill and expertise to identify the smallest of errors in the reimbursement process. The top of the chart advantages that you will receive include 99.9% overall accuracy rate, 80% reduction in overhead costs, and 100% compliance with HIPAA guidelines.

When it comes to covering end-to-end revenue cycle management, outsourced healthcare billing companies stay one step ahead. They provide pre-billing (documentation, eligibility verification, prior authorization) and post-billing (claims submission, denial management, AR follow-ups) services. If your clinic is in urgent need of virtual assistant support, you will benefit from these third-party billing companies. Their services, like patient appointment scheduling, answering patient inquiries, setting up reminders, and responding to voicemails, enhance virtual assistance in your GI practice. If you are struggling to follow the performance metrics for successful reimbursement, outsourcing is the correct option for you to boost your revenue.