How Gastroenterology Billing Services Prevent Revenue Loss

Practices believe that revenue loss begins or gets triggered by one large mistake. This remains true for gastroenterology practices as well.

Things like a missing modifier, weak A/R follow-ups, delayed prior authorization, incomplete procedure notes, or a missed modifier can trigger reduced collections and increased operational pressure.

This is why many practices are gradually shifting towards outsourcing or bringing in external gastroenterology billing services. The reason behind this shift is simple: they are specifically trained to handle a GI RCM and can play active parts in improving revenue.

Why Revenue Loss Is Common in GI Practices?

One important thing about gastroenterology is that it is a procedure-heavy specialty. This means that there are several different processes like colonoscopies, upper GI endoscopies, biopsies, capsule endoscopies, ERCPs, etc.

All of which require detailed and precise documentation to back things up and more. In fact, even a routine colonoscopy could become a financial complexity if a screening service becomes a diagnostic service due to finding.

Payers have a tendency to apply different rules as per context and procedures. This is one of the biggest reasons why revenue loss is so common in GI practices. For example, a procedure could be clinically valid, but still the claim can still be denied on the grounds of incomplete documentation.

All these factors play a major role in making gastroenterology billing a complex set of affairs that can only be handled by a specialized team of experts.

Where Revenue Leakage Starts in the Billing Cycle

Revenue leaks in GI practices rarely begin with denial. In fact, the whole thing begins way before the patient is even looked over by a specialist. Therefore, practices that do not outsource rarely understand this dynamic and chase denials.

Revenue begins at a small scale like an incorrect detailing during the onboarding or a missed prior authorization. All of these things have the potential to cascade into something bigger as it reaches the reimbursement phase. At which point, the revenue pipeline gets clogged.

Eligibility and Prior Authorization Gaps

One of the biggest areas where GI practices could observe a leak is eligibility verification and prior authorization lapses. Being cavalier with either of the two can be disastrous for the revenue.

Eligibility verification primarily confirms whether a patient’s coverage is active, subsequent benefits that he or she is getting, and whether the requested procedure requires authorization or not. If skipped, then the entire service performed by the provider could become non-payable.

The next component of the gastroenterology billing is prior authorization. Some procedures tend to come up with an authorization requirement. If a practice fails to comply, then it could lead to complete denial altogether.

This is why established and experienced gastroenterology billing services start the patient journey with a diligent look at the eligibility and prior authorization, to minimize the denial rate.

Claim Denials, Underpayments, and A/R Delays

Most RCM experts see denials as the biggest revenue threat. However, underpayment is the real deal breaker. Underpayment usually looks like a claim processed at a lower allowed amount or deny a bundled service incorrectly or a payer adjustment that does not match the contract. Now, the biggest problem with underpayment is that it often remains unnoticed until it is too late.

Therefore, without key processes like payment posting and contract validation, tracking these leaks can be quite herculean. Subsequently, there is also the question of A/R delays. In general, it noticed that the longer a payment remains in the A/R, the chances of recovering it dwindle considerably.

How Specialized Billing Prevents Lost Revenue?

By this time, it should not be a mystery that gastroenterology billing is a complicated process to begin with. As a result, limitedly trained in house teams might not be the right people for the job. As a result, providers need to rope in specialized billing teams that are capable of handling all the unique challenges with the help of certain processes:

Accurate Coding for GI Procedures

GI coding is not a linear affair by any means. The discipline requires a detailed insight into the world of medical coding like CPT, ICD-10, and HCPCS. Moreover, the team or the individual also needs to have a clear insight into how one procedure could have different codes.

Denial Prevention and Root-Cause Analysis

One thing about denial management is that many providers tend to approach it as a reactive system. However, that is not the right way to proceed. Creating a more preventative denial management system protects the base line better than a reactive one.

Coupling the preventative denial management with a detailed root cause analysis could help facilities have a better insight into denials. This insight can then be used to create systems that allow facilities to avoid denials altogether.

A/R Follow-Up and Payment Recovery

Up next, there is A/R follow up. Systematic A/R follow-ups help protect the revenue that has been earned but not yet collected. The right team can reduce days in A/R with the help of careful segmentation by unpaid claims, payer, balance, denial reasons, etc.

After the segmentation, the team can effectively follow up and look and expedite the payment. This not only helps with the days in the A/R but also with reducing write-offs, as well as improving cash flow predictability simultaneously. Hence, making the entire process more impervious to unfortunate surprises.

Why Outsourcing Supports Faster ROI

The primary reason behind outsourcing external gastroenterology billing services is simple: efficiency and accuracy. GI billing processes can morph contextually. This is why, having a team that ‘also does billing’ can never stay on top of the changing dynamics of GI billing.

Therefore, having a dedicated team is the way to go. Then again, picking any random RCM partner can never be fruitful. Providers need to go deeper and look for partners that demonstrate certain markers like:

• Supports all EHR/EMR systems.
• Dedicated FTE for every account.
• 97% first-pass rate.
• $7 per hour, all-inclusive service charge with no hidden fees.

These KPIs are crucial as they demonstrate efficiency and accuracy. Hence, providers should only go for names that demonstrate similar metrics or KPIs.

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