Recover Underpayments with an Outsourced Gastroenterology Billing Company

Every gastroenterology clinic faces unique challenges in both patient treatment and billing operations. Submitting insurance claims does not guarantee payment of GI services. There are situations where claims can be rejected, denied, or underpaid. The underpaid claims are difficult to detect because the provider may mistakenly consider the claim as resolved. These underpayments occur when payers pay gastroenterologists less than the amount they are entitled to receive. When the rate of underpayments increases, providers start losing a significant amount of revenue. Thus, identifying the issues and correcting them is vital to reduce underpayments in gastroenterology reimbursement. A professional gastroenterology billing company helps gastroenterologists reduce underpayments besides providing other benefits.

Understanding the concept of underpayments in GI billing

The primary reason why gastroenterologists submit insurance claims is to get payments for services. However, in many cases these claims are often rejected or underpaid. When we mention a claim is rejected, it means that no payments have been made by the insurance company. When a claim is underpaid, the situation is different because payment is made in lesser amounts.

In gastroenterology billing, underpayments may occur from incorrect fee schedule application, payment calculation errors, and improper contractual adjustments. As a result, both cash flow and revenue generation of gastroenterology clinics are affected. When payment discrepancies are repeated across thousands of claims, it creates a significant gap between the revenue earned and revenue collected. The purpose of a gastroenterology billing company is to identify these gaps and reduce billing errors. This allows providers to get proper payments and ensure an uninterrupted cash flow.

What causes claims to be underpaid in GI reimbursement?

Gastroenterology billing can sometimes become challenging for gastroenterologists, which leads to underpayments. The other reasons behind underpaid claims include the following:

1. Incorrect contractual reimbursements – Most people in the US have a contract with the insurance company which includes all the information required for reimbursement. Incorrect contractual reimbursement occurs when an insurance payer pays a gastroenterology practice an amount that differs from the amount it is contractually obligated to pay for a covered service.

The provider and the payer have a mutually agreed reimbursement arrangement which is usually based on contracted fee schedules and payer-specific payment rules. The difference between the actual payment and the expected contracted amount may represent an underpayment.

2. Coding and modifier errors – These errors occur when a gastroenterology claim uses an incorrect procedure code, omits a required modifier, or applies a modifier incorrectly. These errors can cause an insurance payer to reimburse the claim at a lower rate than expected bundle services that should be separately payable or deny part of the claim.

Coding is an essential component of gastroenterology billing because a single patient encounter may involve multiple procedures and services.

Additionally, modifiers can indicate that a GI service was distinct from another service performed during the same encounter. Lack of modifiers can cause the claim to be partially paid by the insurer.

3. Bundling issues – Combining the reimbursement for two or more services into a single payment causes bundling issues. Payers use bundling rules to prevent separate payment for services that are considered integral to another procedure. Incorrect application of these rules can result in lesser reimbursement for the practices. Bundling is especially important because a single endoscopic procedure may involve several related services, such as examining the digestive tract and performing additional interventions.

Most of these reasons occur due to inefficient billing techniques and lack of RCM knowledge. With the help of an expert gastroenterology billing company, providers can improve revenue generation by reducing underpayments.

Ways in which outsourced companies can reduce underpayments in GI billing

• Payment posting and reconciliation – These processes are used by outsourced companies to verify that insurance payments and patient payments are recorded accurately. The billing team reviews the electronic remittance advice (ERA) and explanation of benefits (EOB) to determine how each claim was processed.
• Detecting underpayments – Most billing companies help practices identify underpayments by comparing actual payments with expected reimbursement and investigating claims with unexpected payment differences. After a claim is underpaid, the billing company may contact the payer or file an appeal with supporting documentation.
• Denial management – An outsourced gastroenterology billing company uses denial management to help practices recover eligible revenue. If the denial stems from a fixable billing mistake, the team submits a corrected claim with the necessary changes. This helps gastroenterologists recover outstanding amounts that can otherwise lead to revenue loss.

Hiring the right billing partner for optimum results

Underpaid claims can become a serious GI billing concern if they are not corrected. Moreover, providers must hire a company that has the expertise in handling GI underpaid claims. If clinicians find it difficult to improve revenue cycle management, outsourcing can be the best option for them. However, contacting the right billing company with excellent client references can also help in improving gastroenterology reimbursement.