Quick Tip: Mastering Billing Challenges for 2025

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Thank you for listening to TMA's Practice Well podcast. TMA,
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helping you improve the health of all Texans.
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Music.
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Hi, I'm Cara Benson. I'm the director of TMA's Physician Payment Resource Center.
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I've been with TMA for over 12 years, and I've been in the medical field for over 20.
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In 2023, I assisted physicians in recovering over $3.8 million,
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and I'm excited to see what 2025s bring.
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Today, I have with me Alexis. Hi, I'm Alexis Harvey.
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I work with Clara and Mary and TMA's Physician Payment Resource Center.
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I'm a certified professional coder, and even though I'm fairly new to TMA,
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I'm excited to bring fresh eyes to help physicians with their billing and coding problems.
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Thank you, Alexis. So we want to help physicians and their staff with preparing
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for the 2025 year and whatever billing challenges and new coding and billing
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requirements come into play.
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First, let's start with the strategies. How can a practice optimize the reimbursement in 2025?
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I think that practices should implement policies and processes for regular training
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and education for staff.
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This could be used with conducting regular in-house audits and using the audits
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for questions and open discussions for staff to go over any problem areas or
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trends or recurring issues along with the resolutions for some of these major issues that they find.
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They can use key performance indicators to run reports to kind of see where
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the overall, I guess you could say,
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health of the practice is at and just kind of getting into a routine of reviewing
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and analyzing these reports, again, to help identify problem areas.
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They can use this information to set realistic goals or benchmarks that I think
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would help maximize their reimbursement rates and revenue.
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Now, you mentioned training and education for staff, which we all know is highly important.
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Where can physicians and their staff obtain information going into 2025?
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As we know that insurance is ever-changing, and we also have the Medicare fee
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schedule that just came out.
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So where else can they go to obtain information?
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I think some of the major websites that they would be able to use would be,
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you know, the AMA's website,
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CMS websites, and just kind of following up and monitoring the specific carrier
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website for any updates and policy changes.
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Of course, if you're a member, TMA is also a really good resource to reach out
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to and just making sure that you're constantly monitoring and checking and then
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educating on any updates for policies, codes.
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Guidelines, compliance, just to make sure that everyone is up to date and will
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help prevent any issues with claims denials and reimbursement. All right, good.
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Now, you mentioned claim denials.
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So going into coding and billing rules,
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as practices look at their accounts receivable and start working the 2024 denials
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more, what are the common errors that they're going to see?
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And how can they be avoided? Some of the major issues with claims denials will
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still kind of be the same that we've been struggling with,
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you know, whether it is a claim denial for documentation errors or,
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you know, using the wrong codes, unbundling or upcoding or downcoding.
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You know, these are the same issues that have been around. And I think just
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making sure that you're checking for the updates on these changes to reflect,
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you know, accurately the 2025 guidelines.
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What about modifier usage? Modifier usage is also a big one.
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And I think that it's one of those things that is just very easy and basic to
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use, but it's just either forgotten or it's used incorrectly.
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And, you know, whether it is doing, you know, the left and right modifier and
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making sure that it matches the specific diagnosis code when the laterality
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is important for the diagnosis code.
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So, you know, that's a very, very common error that I think,
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you know, just paying more attention to can help prevent some of the denials.
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So, Alexis, are there any Texas-specific considerations that physicians and
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their staff should be aware of?
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Some of the major ones that we've noticed would be the impacts from the Medicare
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physician fee schedule and just that it's introducing some new changes.
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For example, the removal of code G0511 for chronic care management.
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And the rule indicates that they will no longer be able to use this code for
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chronic care management and will have to bill their care using the same code
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from the traditional ambulatory codes.
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And this will affect reimbursements and just will lead to a substantial drop
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in reimbursement rates.
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Another one would be the coordination of care services. I think that this is
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definitely going to be a big one because more practices are starting to ask
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and inquire about using these services because they haven't been using them.
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And so an example would be one of the rules would be the addition of a few codes.
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And it's just something that I think we'll see issues with because they've never
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billed for it before. So we can kind of expect to see some new issues with the new billing codes.
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Another thing I think would be for the addition advanced primary care management,
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which focuses on preventative care and how it's offered to patients.
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And these would have the impact with, again, chronic care management,
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telehealth services, transitional care management. So I think those are some
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of the basic ones that we'll definitely see.
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Yeah, and as these new codes roll out and physicians and their staff learn how
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to use them, there's a good chance that we will start seeing more denials.
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How can they combat that? What are the best practices for managing and reducing
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claim denials? And how should they appeal?
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What are the best practices for appealing as well? I think that the first thing
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that they could really focus on is being familiar with some of the new physician
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fee schedule changes, along with, let's say,
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the conversion factor and just kind of planning ahead and knowing that they
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might see a decrease in Medicare payments due to the new conversion factor.
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And then kind of just with that in mind, then kind of really dig into more of
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the denials and appeals. Is it something that's new?
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And that's why they're being denied, because they don't know how to use it quite yet.
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But, you know, just making sure that you're constantly monitoring these changes
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and then communicating with your staff and teaching them, you know,
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what these new policies and changes are.
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And I think will definitely help with preventing more claims denials.
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And when they are checking for the client and looking at eligibility and looking
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at benefits, is it better for them to get a verbal reference or is it better
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for them to get that information in writing?
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I think it would always be in writing.
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However, if it is verbal communication, just making sure that you are keeping
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a reference number and having that documentation so that you have that paper trail.
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And whether it is a screenshot or just some sort of documentation that you can
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maybe print out and use, again, to have that paper trail and to make sure that you're covered.
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And that way you're also providing the correct and supported documentation needed.
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Thank you. When they are working on their appeal process, what is the most effective way to do the appeal?
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Do they just need to say, you know, refer to their medical records or is it
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best to include medical records and provide a detailed summary of what the problem is?
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I would definitely recommend not using C medical records.
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You definitely want to make sure that you include specific details and not just
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a generic form that doesn't have the supporting documentation to support your
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reason for why you maybe disagree with the claim denial.
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Looking at cost estimators and knowing where to find them and how they apply
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to each patient health plan regarding what's covered, requirements needed,
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what supporting documentation is needed,
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even just timeframes too of when you need to have these appeals submitted and
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those general guidelines and just following them.
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Okay. And when they are looking at the claim denials and looking at appeals,
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we do tend to see that the claims have been cycled, whereas the appeals are
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not being done in detail.
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It's more that the claims are just being resent.
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Is that really the best practice? Or what are the implications of just cycling
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a claim again without correcting it? Definitely, you can't just cycle the claim.
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You definitely need to make sure that you investigate the reason for the denial.
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Know if it's, you know, whether it's a modifier issue, if it's a diagnosis code,
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if it's just missing patient information or insurance information,
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or even, you know, the provider identification number is maybe typed in correctly.
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Make sure that you have all this documentation that you
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include in the appeal before you
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actually send it you know make sure that you're prepared and having all that
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documentation creating a paper trail making sure that
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you are also keeping track of your investigational resources to support your
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reason and i think that that will definitely help kind of way whether or not
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the claim is going to be denied again and or it will be accepted and then you're
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and then you're done and when they cycle the claims when they,
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instead of filing a corrected claim, do they get charged every time they just submit it?
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Kind of interesting was when looking into some of the reasons for claim denials
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and just understanding the difference between a claim denial and a claim rejection
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and the different steps to handle those.
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If it's a denial, then maybe it's just the correction and you don't actually
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need to submit an appeal.
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But if it's a denial, making sure that you know how to do the denial with,
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you know, the documentation, the, you know, investigate what the reason is for,
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make sure that you have an understanding of the claim code denials.
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Making sure that you have a general understanding of those, I think will really
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help too with preventing claim denials.
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Okay. And on the claim denials, is there a way to determine what's denied,
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what's still outstanding?
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What metrics, I should say, should a practice track to monitor the financial
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health of their billing process?
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I think utilizing those resources available, like the specific carrier insurance websites.
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I know that a lot of them use the availability tool so that they can actually
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go in and see the reasons why claims are denied and the remittance advice on
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how to go about correcting it.
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So Alexis, along the line of seeing denials, what metrics should practices use
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to monitor their financial health of their billing processes?
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One of the most common reports that would be really helpful for practices to
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use would be the aging reports, which coincides with reimbursement and the ability
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to appeal claims in a timely manner.
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The number of days a claim is in accounts receivable reports.
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There is also the first past resolution rate reports, denial rate reports,
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and even something like the bad debt reports are definitely good things to look
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at and keep track of and making sure that you're going over it and going over it with your staff.
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The biggest thing that I would recommend is just making sure that the position
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is involved and stays involved because at the end of the day,
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the physician, they shouldn't remove themselves from the billing part of their practice.
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And I think that it definitely can have some major impacts if physicians do
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remove themselves from the billing part, just because they need to be involved.
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They need to know what's going on. They need to ensure that their staff knows
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what's going on and that they're doing it correctly and following compliance
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rules and regulations. And I think that will definitely help.
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And speaking of keeping physicians involved in the billing operations,
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there are times when their health plan has information behind a provider portal, essentially.
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And one of those things is cost estimators.
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And Alexis mentioned cost estimators a little bit ago.
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And what they are is a way for staff and physicians to pool patient information
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regarding their benefits.
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So you can see what is expected as far as deductible, co-insurance,
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co-pay, what the health plan will pay for in regards to services.
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So it's just another important tool that will help cut down and minimize having
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to deal with denials and the appeal process.
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Are you seeing an increase in use of AI?
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As far as technology, I would say that we really haven't seen a lot of issues
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or it hasn't really been brought up too much regarding AI technology with billing and coding,
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just because there's a lot of mixed views on whether or not I think people think
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that it's useful or if it's not.
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It's just a lot of mixed views right now regarding AI technology for billing
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and coding. One thing to note about AI is even though we are not seeing AI with
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billing and coding right now, we could see an increase in it.
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One thing to keep in mind is if you do choose to use AI for billing and coding,
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you still need to have a human eye on it to make sure that anything that goes
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out is correct. A really good point.
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And I would also recommend that before you send anything out,
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just making sure that you have a trained professional looking over things before
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anything is sent out. Thank you, Alexis.
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And we've spoken a lot about physicians and staff and what their role is,
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but let's transition to the patient because they are just as important in this whole process.
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And so how do we bring in the patient in this?
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Because in 2025, we're going to see higher deductibles, which is going to mean
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more patient responsibility.
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So what is the best practice for physicians and speaking with their patient?
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I think the biggest thing always is going to be just communication and education.
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Making sure that you're communicating with your patients, you know,
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where they can find the documents and available resources, making sure that
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the patient is aware of the payer policies and what's expected of them.
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The shift focusing more on quality over quantity could lead to new or updated
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standards and guidelines for physicians and their practices.
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And, you know, just knowing that by not following these new standards,
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how it's going to impact their cash flow, something like making it easier for
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patients to access online payment options or just accepting more variety of payment options.
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Or does the patient know how to understand and read an explanation of benefits?
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And if they don't, what is the physician doing to teach that patient how to
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read these statements so that in the end it will help with the payments?
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You know, making sure that practices are taking the copayments up front before services are provided.
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This was something I read about, which I thought was kind of funny,
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was how even something as simple as making sure that your front desk staff know
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where the closest ATM is. That way they can, if their office doesn't have an ATM inside.
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It's just another way for the practice to get the patient to pay what's owed
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up front for the services to kind of prevent that extra cost of mailing billing statements.
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I think it's just an easy way to kind of help prevent some of these issues.
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Okay, there are so many ways to combat the challenges for 2025.
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What is the one piece of advice that you would give a medical practice to overcome these challenges?
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I think the biggest thing would just be to remember the basics and remember that help is available.
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TMA members can check the episode
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description for a link and a number to contact us for any help needed.
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Yes. And with Physician Payment Resource Center, we see a multitude of issues.
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And one issue in particular that stands out in my mind, and we haven't covered
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it in this episode, but just to touch on it a little bit is in regards to credentialing.
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While we don't do credentialing in detail, we can help with communication and
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help figure out what it is that is keeping a physician from receiving the payment that is due.
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This one in particular, the claims for processing is out of network and come
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to find out the physician was actually in network.
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And we were able to fill that gap in communication and get everything clarified
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and the health plan paid.
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So it was a huge win and physicians could continue to see the health plan in those patients.
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Alexis, thank you for sharing the tips to overcome billing challenges in 2025.
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And to our listeners, we hope you found this episode beneficial.
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Check out the episode description to get the link and contact info to reach
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TMA Physician Payment Resource Center.
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Remember to like and follow TMA Practice Well Podcast to receive more helpful
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tips. Until next time, stay well.
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Music.