BC ADVANTAGE - July/August 2025

PROVIDING RESOURCES FOR MEDICAL PRACTICES AND THE PEOPLE BEHIND THEM

JULY / AUGUST 2025

BEST PRACTICES TO

OVERSEE

YOUR BILLING

AND COLLECTIONS OPTIMIZE YOUR BILLING AND PAYMENTS WORKFLOW: THREE WAYS TO IMPROVE EFFICIENCY AND REDUCE WASTE

HANDLING RISK ADJUSTMENT AND HCC CODING IN VALUE-BASED CARE TURN DENIALS INTO DOLLARS AND ENHANCE FINANCIAL STABILITY IN 2025

EDITOR’S NOTE

It’s summer! Who doesn’t love summer?

The warm sunshine/the violent thunderstorms, the singing birds/the biting mosquitoes, the bountiful gardens/ the growing weeds—can’t have the good without the bad, right?

So about that sunshine—when you go out in it, don’t forget the sunscreen!

Our healthcare awareness spotlight in this issue is on UV awareness, i.e., skin cancer prevention. Did you know that more than two people die from skin cancer in the U.S. every HOUR? That tragic statistic definitely reminds me to cover up and slather up. Yes, it takes a bit more mindfulness and a few minutes away from fun, but it’s so worth it.

A few years ago, I saw my dermatologist for my annual skin check, and she spent a little more time looking at my shoulder than I would have liked. Long story short, they called it a “pre-melanoma,” but I have a fantastic Frankenstein scar on my left shoulder to remind me how much worse it could have been. When my surgeon asked me about any concerns at my follow-up, and I told him I felt like Frankenstein, he said, “If that’s the worst of it, then I did my job.” What a sober reminder, for sure! So now it’s fishing shirts vs. tank tops, rashguards vs. swimsuits, hats vs. ponytails, and, of course, when and where skin isn’t covered, it’s sunscreen—30+ SPF and often is the way to go.

Speaking of best practices, our cover this issue discusses the best practices to oversee your billing and collections.

Shannon DeConda, a partner at

DoctorsManagement and the founder and president of NAMAS, offers a practical framework for real-world oversight. As you read it and reflect on your revenue cycle, think about what you are monitoring—and how often. Just like sunscreen, how you do it matters!

We have other articles on handling risk adjustment and HCC coding, turning denials into dollars, current mammography topics, the impact of VBC and AI, a recent Justice memo, the reimbursement plateau, zero-paid claims, optimizing billing, negotiating insurance contracts, real-time data analytics, and cybersecurity. If (or since!) you are in the billing/coding/medical practice industry, these are all relevant topics worth reading!

So enjoy the read—and enjoy your summer! Grilled burgers and juicy watermelon and cool fireworks, oh my!

Never mind the pesky flies and army of ants and smell of sulfur—all of that will be a distant memory too soon!

If you need me, you might find me in the yard trimming trees so I can hang my hammock. Because is there really anything more relaxing than sitting in the shade of a tree, hanging in a hammock, reading a book (or a magazine!), sipping on homemade, ice-cold lemonade, and feeling the warm breezes of summer? I certainly don’t think so! I guess good can exist without the bad! Unless, of course, those ants want my lemonade!

editor Amber Joffrion, M.A. editorial@billing-coding.com

ceo - publisher Storm Kulhan storm@billing-coding.com

coo Nichole Anderson, CPC nichole@billing-coding.com

subscriptions manager Ashley Knight ashley@billing-coding.com advertising sales@billing-coding.com Renewals: Keep your rate locked in for life! www.billing-coding.com/renewals Change of address: Email subscriptions@billing-coding.com or call 864 228 7310

editor Amber Joffrion, M.A.

BC Advantage is published bimonthly by Billing-Coding, Inc. P.O. Box 1388, Newland, NC 28657 Phone: (864) 228 7310 Fax: (888) 573 7210 email: subscriptions@billing-coding.com / www.billing-coding.com

CONTENTS MAGAZINES | CEUS | WEBINAR JULY/AUGUST 2025 - ISSUE 20.4

ON THE COVER

FEATURES 16 Data Unveiled: The Impact of VBC and AI on Preventive Care and Chronic Disease Management 20 The May 12, 2025 U.S. Department of Justice Memo 22 The Reimbursement Plateau: Breaking Through the Limits of Traditional RCM 24 Understanding and Defending Against

Best Practices

to Oversee Your Billing and Collections: A Practical Framework for Real-World Oversight

Zero-Paid Healthcare Claims 34 Healthcare Awareness Spotlight: July is UV Awareness Month 36 Optimize Your Billing and Payments Workflow 40 How to Successfully Negotiate

FEATURES 06 News / Updates 10 Handling Risk Adjustment and HCC Coding in Value-Based Care 12 Turn Denials Into Dollars and Enhance Financial Stability in 2025 14 Current Topics in Mammography

Insurance Payor Contracts for Better Reimbursement Rates 44 How Real-Time Data Analytics Is Revolutionizing Patient Care 48 The Critical Importance of Cybersecurity for Medical Office Managers

EXPERT CONTRIBUTORS THIS ISSUE

Allzone, established in 2005, is a leading offshore medical billing company that provides medical billing, coding, and RCM (revenue cycle management) services to clients nationwide. www.allzonems.com

Nathaniel Arana, Principal, NGA Healthcare, has many years experience in business and in the healthcare field.

Nathaniel earned a management degree from the Eller College of Management with an emphasis in operational management and organization. www.ngahealthcare.com

Matthew Bernier serves as Product Management Director and VP for PayerSync at Rectangle Health, leading agile teams focused on building high-impact integrations and functionality across patient payments, engagement, and compliance. www.rectanglehealth.com

Karen Blanchette, MBA, is the Executive Director of PAHCOM. The PAHCOM collaborative network enables solo providers and small group physician practices to access focused information vital to managing their healthcare businesses effectively. https://my.pahcom.com/

Sandy Coffta is Vice President of Client Services at Healthcare Administrative Partners. www.hapusa.com

Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CMPM, CPMN, is the Director of Coding and a partner

at DoctorsManagement, as well as the founder and president of NAMAS. https://namas.co

David L. Morris is EVP and Chief Commercial Officer at Cedar Gate Technologies. www.cedargate.com

Jayashree Selvaraj is the manager of the medical coding and CDI services for AGS Health. www.agshealth.com

Sonal Patel, BA, CPMA, CPC, CMC, ICDCM, is CEO and Principal Strategist of SP Collaborative, LLC. www. spcollaborative.net

Vidisha Pulaguru Srikanth is a Senior Product Manager, Practice Management at RXNT. www.rxnt.com

Rachel V. Rose, JD, MBA, (Houston, Texas) is a disciplined, empathetic, and tenacious attorney advocating for and winning desired legal outcomes for national and international clients. www.rvrose.com

Patricia Smith is the Director of Revenue Cycle Consulting at SYNERGEN Health. www.SYNERGENHealth.com

Kelsey Zaporowski, CollaborateMD. CollaborateMD.com

EXPERT CONTRIBUTORS THIS ISSUE We are always interested in hearing from any industry experts who would like to get published in our national magazine.

Email us at editorial@billing-coding.com to request a copy of our editorial guidelines and benefits.

BC Advantage Magazine

www.billing-coding.com

5

NEWS HHS Updates Regulatory Guides for the Safe Use of EHRs The U.S. Department of Health and Human Services (HHS), via the Assistant Secretary for Technology Policy, has released the updated 2025 SAFER Guides—a set of seven documents with 524 examples—to help healthcare organizations enhance the safety and effectiveness of their electronic health record (EHR) systems.

Key updates include: Incorporation of 21st Century CURES Act provisions, such as AI use in clinical care, cybersecurity, and FDA-approved device data integration.

New tools for self-assessment scoring and evaluating the quality of recommendations.

A five-point adherence rating scale and a threelevel evidence hierarchy.

A revised High Priority Practices Guide tailored for clinicians in merit-based incentive programs.

The guides were reviewed by experts in informatics, clinical care, EHR vendors, and patient safety fields. Emphasis was placed on evolving practices like patient access to clinical notes and results.

The SAFER Guides, first released in 2014 and last updated in 2016, are now part of the CMS Promoting Interoperability Program, requiring hospitals to perform annual EHR safety selfassessments. Policymakers expect organizations to adopt more best practices annually to improve scores and safety outcomes. https://www.healthcareitnews.com/news/ obama-signs-21st-century-cures-act-law-fundingprecision-medicine-cancer-moonshot-ehr https://www.healthit.gov/topic/safety/saferguides

6

BC Advantage Magazine

www.billing-coding.com

Decoding Healthcare and How AI Is Revolutionizing Medical Coding: Fathom Featured in MedTech Gurus Podcast MedTech Gurus is a podcast dedicated to helping medical device executives stay on the leading edge of their industry.

Each episode features an interview with a thought leader or practitioner, discussing topics like: sales force, innovation, patient outcomes, emerging technologies, supply chain, group purchasing organizations, device launches, value analysis, biotech, and more.

As organizations navigate chronic staffing shortages and increasing financial pressures, AI is playing a major role in providing much-needed relief. In a recent MedTech Gurus podcast hosted by Thomas Hickey, Fathom CEO Andrew Lockhart explored three key ways autonomous coding is making an impact. https://fathomhealth.com/insights/decoding-healthcare-andhow-ai-is-revolutionizing-medical-coding-fathom-featured-inmedtech-gurus-podcast

How the Health Tech Investment Act Could Reshape Medicare Reimbursement for Algorithm-Based Services

Clarifying Billing for CPT 52353 When Treating Multiple Same-Side Stones

The Health Tech Investment Act (HTIA), introduced in April 2025, seeks to modernize Medicare by creating a clear and dedicated reimbursement pathway for algorithm-based healthcare services (ABHS)—AI-powered, FDA-authorized medical devices that provide clinical recommendations.

A common coding question arises when two stones on the same side (e.g., left kidney and left ureter) are treated using ureteroscopy and laser lithotripsy. In the past, guidance suggested billing CPT 52353 twice— once for each stone in a different structure—using a modifier like -XS or -59.

Key Provisions:

However, billing rules have evolved.

Defines ABHS as a distinct Medicare service category.

Here’s what you need to know now:

Requires CMS to assign eligible services to a “New Technology” payment class.

CPT 52353 has a Medically Unlikely Edit (MUE) of 1 with an Adjudication Indicator of 2, meaning most payers allow only one unit per date of service, regardless of how many stones are treated on the same side.

Guarantees 5 years of separate reimbursement to encourage adoption.

Allows billing even if AI tools are used alongside other procedures.

Bases payments on real-world cost data (e.g., subscriptions, staffing, overhead).

Stakeholder Impact: Medical Device Companies: Gain predictability and faster access to reimbursement but must still prove cost-effectiveness.

Limitations: Only FDA-authorized devices qualify; some AI software (like clinical decision support tools) may be excluded if not FDA-regulated.

FDA Role: Already cleared over 1,000 AI devices, mostly in radiology; continues issuing guidance on AI regulation.

For Providers & Patients: Clinicians: Can bill separately for AI-enhanced tools, supporting faster adoption.

Patients: May benefit from quicker, more accurate diagnoses and more equitable access to advanced care.

Long-Term Outlook: While HTIA may raise short-term Medicare costs, its structured reimbursement model aims to promote innovation, reduce long-term waste, and support responsible deployment of AI in healthcare.

Although clinical guidelines (e.g., from the American Urological Association) still consider the kidney and ureter as separate structures, payors now interpret the rules more strictly.

Specifically, the parenthetical note for CPT codes 52332, 52353, and 52356 advises not reporting these codes together when performed on the same side.

Many payors now extend this to disallow multiple units of 52353, even if stones are in different anatomical locations.

Appeals typically don’t change the outcome, as payors enforce these rules literally, rather than based on clinical intent.

Some practices may still get separate reimbursement depending on the payor, but this is increasingly rare.

If two stones are treated on the same side, consider using modifier -22 to indicate increased complexity— only if the documentation clearly supports the extra effort involved.

Bottom line: Despite earlier guidance, only one unit of 52353 is typically billable per side, per date of service. To avoid denials, follow payor-specific policies, and use modifier -22 when appropriate and well documented.

BC Advantage Magazine

www.billing-coding.com

7

NEWS CMS to Immediately Expand Medicare Advantage Audits in Major Enforcement Push On May 21, 2025, the Centers for Medicare & Medicaid Services (CMS) announced a sweeping expansion of its auditing activities targeting Medicare Advantage (MA) plans.

As part of this initiative, CMS will audit all eligible MA contracts for each payment year going forward. For audits already in progress, CMS aims to accelerate completion for Payment Years (PYs) 2018 through 2024, addressing longstanding backlogs. While the Trump Administration has criticized CMS for delays in finalizing these audits, CMS now pledges to complete all audits for PY 2018–2024 by early 2026.

CMS conducts Risk Adjustment Data Validation (RADV) audits to verify that diagnoses used for risk-adjusted payments are backed by documentation in patients’ medical records.

Unsupported diagnoses can lead to recoupment of overpayments to MA plans.

To accelerate and expand RADV audits, CMS is implementing a two-pronged strategy: Technology-Driven Review: CMS will deploy advanced technology to review medical records and identify unsupported diagnoses, enabling the agency to audit 8

BC Advantage Magazine

all 550 MA plans annually— up from just 50–60 plans currently. The sample size per plan will also grow from 35 to 200 records annually.

Workforce Expansion: CMS plans to dramatically increase its medical coding staff—from 40 to approximately 2,000 coders by September 1, 2025— to enhance manual verification of flagged diagnoses and improve audit throughput.

This aggressive expansion aligns with the Trump Administration’s broader agenda to combat healthcare fraud, waste, and abuse.

MA plans found to have received overpayments may seek reimbursement from downstream providers, potentially exposing them to compliance risk depending on contract terms. As a result, providers and plans alike should prioritize proactive compliance measures, especially in auditing and monitoring practices.

CMS’s latest RADV final rule, effective April 3, 2023, revised the audit methodology to improve MA program integrity and payment accuracy.

Proskauer will continue to track developments and their implications for both Medicare Advantage organizations and their provider networks.

www.billing-coding.com

Veteran’s $43,000 Medical Debt Waived, Easing Burden Amid ALS Battle Warren Findley, a U.S. Air Force and Coast Guard veteran, has been granted significant financial relief after the South Texas Veterans Health Care System waived a $43,000 medical bill.

Findley, who is living with ALS, expressed deep gratitude for the decision. His wife, Madi, echoed the sentiment, saying, “It’s one less thing I have to worry about.”

While Warren continues to face the daily challenges of ALS alongside Madi and their three daughters, the removal of the massive debt brings muchneeded peace of mind. The waiver followed weeks of uncertainty, advocacy, and pressure. Although the Department of Veterans Affairs did not admit fault, they acknowledged that Findley was not responsible for the charges. “They did the right thing,” he said.

Despite this personal victory, Findley remains outspoken about deeper issues within the veterans’ healthcare system. “I think they’re hoping that as long as you don’t make a stink, you’ll just slip through the cracks,” he said. “But the system needs to be fixed.” He hopes others facing similar struggles in San Antonio and beyond will see positive change.

According to a statement from the South Texas Veterans Health Care System, the VA’s Debt Management Center and the Committee on Waivers and Compromises determined that collecting the debt would be “against equity and good conscience,” leading to the official waiver.

Madi has since left her teaching job to care for Warren full-time. “It’s not easy, but it’s what our family needs,” she said.

Through the adversity, Warren remains thankful. “We won’t forget to say thank you while the cameras are on—thank you, Taylor, we appreciate you,” he said, referring to one of his advocates.

Now, with the debt behind them, Warren can rest easier knowing his family isn’t carrying the financial burden of his care.

American Institute of Healthcare Compliance www.aihc-assn.org

AIHC is a licensing/certification partner with CMS offering in-person training and online certification courses The American Institute of Healthcare Compliance is a national organization for Healthcare Professionals with over 30,000 members & subscribers. We are recognized as a healthcare education organization with the Internal Revenue Service (IRS) operating as a Section 501(c)(3) nonprofit corporation. Revenue generated by AIHC is reinvested in the organization to pursue its educational purpose and benefit its members.

We maintain an A+ Rating with the Better Business Bureau by providing quality online courses and live events to train and credential healthcare administrators.

Contact us today!

Call: 330-241-5635 email us: Info@aihc-assn.org BC Advantage Magazine

www.billing-coding.com

9

Handling Risk Adjustment and HCC Coding in Value-Based Care

V

alue-based care (VBC) advocates for a healthcare delivery model that shifts from a volume-based approach to one that aims to align healthcare outcomes with payments for services tied directly to the quality of care provided and patient outcomes achieved.

This model encourages healthcare providers to focus on delivering high-quality care to patients while optimizing healthcare resources.

Financial incentives seek to streamline costs to make high-quality care more accessible and affordable while creating a more efficient, patient-centric healthcare system. The Affordable Care Act (ACA) and the transition to electronic medical records (EMRs) acted as catalysts, with the introduction of ICD-10 coding classification standards further ushering in an era of unprecedented detail and specificity in healthcare documentation.

10

BC Advantage Magazine

www.billing-coding.com

Significance of HCC Coding in Value-Based Care At the heart of the value-based care model is the concept of risk adjustment and risk adjustment factor (RAF) scores, which is primarily facilitated through hierarchical condition category (HCC) coding mechanisms. By categorizing various diagnoses, HCC coding is instrumental in predicting healthcare costs for patients. This method allows for a more complete understanding of a patient’s health status, enabling healthcare providers to allocate resources more effectively and ensuring that patient complexities and care needs are accurately reflected in healthcare reimbursements for delivered services.

Integrating advanced technologies, such as artificial intelligence (AI), machine learning (ML), and natural language processing (NLP), automates and streamlines medical coding processes to improve accuracy and foster a culture that prioritizes patient outcomes and datadriven care. It is also important to invest in education and comprehensive HCC coding training programs for staff.

Expansion of Value-Based Care The successful transition to value-based care is intricately linked to the effective implementation of risk adjustment and HCC coding practices. The future trajectory of valuebased care will emphasize efficiency, cost reduction, and improved patient experiences. Its expansion is expected to include a broader adoption of outpatient clinical documentation improvement (CDI) initiatives focusing on accurate HCC capture, enabling healthcare providers to better serve their patients and improve patient outcomes.

HCC Risk-Adjusted Models Implementation To successfully implement HCC risk-adjusted models, healthcare organizations need to overcome challenges to effectively capture patient data and reduce reliance on manual processes. Challenges include: Documentation deficiencies created when healthcare providers document for the fee for services (FFS) payment model focusing on individual encounters rather than risk adjusted models focused on overall patient health Lack of tools for tracking and maintaining patient diagnoses and aggregate reporting Shortage of medical coding and clinical resources Provider engagement

By accurately capturing the complexity of patient conditions, healthcare providers can ensure a fair and efficient allocation of resources, paving the way for processes that ultimately lead to better patient outcomes and a more sustainable healthcare delivery system.

Jayashree Selvaraj is the manager of the medical coding and CDI services for AGS Health. In this role, she contributes to the development of medical coding and CDI service line strategy and execution.

She has more than a decade of experience in medical coding and training and development. Jayashree holds a bachelor’s degree in biotechnology from Anna University, India. She is also a Certified Professional Coder (CPC) and Certified Risk Adjustment Coder (CRC) from the American Academy of Professional Coders (AAPC). www.agshealth.com BC Advantage Magazine

www.billing-coding.com

11

But, ASCs are particularly hit hard due to smaller size and increased case volume. Increasing denied claims can create an even more enormous administrative burden. Plus, reprocessing claims can lead to significant delays in cash flow.

Increasing Billing Scrutiny

Turn Denials Into Dollars and Enhance Financial Stability in 2025

A

mbulatory surgical centers (ASCs) are unique from their hospital counterparts for many reasons, especially when it comes to finances. Due to leaner margins and smaller administrative teams, having a strong revenue cycle is non-negotiable.

The past few years have been plagued with financial turbulence felt by the entire industry. Fueled by rising denials, staffing shortages, and increasing payor scrutiny, 2025 is shaping up to be more of the same.

However, the right strategies can help your ASC reduce denials and optimize its reimbursements to withstand even the most turbulent of times.

First, let’s take a look at some current challenges putting pressure on ASCs: Denied Claims on the Rise Recent studies show that about 15% of all claims submitted to private payors initially are denied (including those preapproved during the prior authorization process), and fighting denied claims costs $19.7 billion per year. It’s safe to say that denied claims affect all areas of healthcare.

12

BC Advantage Magazine

www.billing-coding.com

Payors are becoming more and more particular about what they will and will not reimburse, and ASCs’ traditional billing models don’t always play nicely with their new rules.

ASCs operate under global billing models to simplify certain aspects of the billing process, but payors may view it as not providing enough information for reimbursement, resulting in a denial.

Complications can also arise when procedures deviate from initial authorizations. For example, any changes during a procedure, even if absolutely necessary, like switching from an endoscopic approach to an open procedure, often result in a denied claim.

Need for Quick Reimbursements Due to ASCs’ lean margins, they often assess a case’s profitability beforehand. So, when there are even minor reimbursement delays, payroll, rent, and vendor payments are all impacted.

If an ASC has lengthy accounts receivable due to rising claim denials, things can get dicey. Once a claim ages to 120 days or more, we like to say they are in the “danger zone,” which means that facilities may not be able to collect those payments at all. If they do, it often requires additional resources, which many ASCs simply do not have.

And, without quick reimbursements, facilities may not be able to make additional investments in things like new equipment or capital expenditures to improve services, both of which can negatively affect staff morale.

Rising Labor Costs and Staffing While more than half of ASCs have experienced an increase in patient volume, nearly 70% are finding it increasingly difficult to recruit skilled operating room nurses (as reported by Becker’s ASC Review).

Staffing difficulties and labor costs are nothing new, and they are usually among the top three pain points that everyone in healthcare faces. Between 2021 and 2023, labor costs increased by more than $42 billion (as reported by the American Hospital Association). And, considering that staffing makes up 60% of hospital expenses, you can easily see why these trends have industry leaders worried.

ASCs contend with narrower financial margins than large hospitals, which makes attracting new talent and retaining existing staff tough. This puts pressure on leaders to operate at the height of their existing capabilities with what they have.

Optimizing RCM in ASCs in 2025 ASC administrators need to adopt strategic approaches to minimize denied claims and ensure the speedy reimbursements they need.

The good news is that there are practical and proven steps to help your team stay profitable: Embrace Automation There’s a misconception that simply hiring more people will solve whatever RCM challenges you’re facing, but that’s often not the case. Without the proper strategies and processes in place, it can actually make things worse.

Instead, ASC leaders should look to automation to streamline processes like verification of benefits and coding. In this case, automation can ensure that claims are accurate before they are ever submitted to help prevent potential errors from happening.

Staffing is usually the most significant line item for ASCs, and embracing automation is an opportunity to minimize these costs, while keeping operations running smoothly and staff morale high. Of course, this does not mean replacing your staff with robots. Instead, it means being able to provide better care because you’re staying profitable.

One extraordinary example I’ve seen is one organization absorbing more than 100,000 additional claims and reducing their aged receivables by 80% with automation technology (reported by SYNERGEN Health in “Transforming End-to-End Revenue Cycle to Fuel Accelerated Growth”).

Focus on Denial Prevention and Management Denied claims pose a huge threat to ASCs. In an industry where we need quick reimbursements to fuel our lean margins, denials are a massive barrier to profitability.

Once you receive a denial, it takes a lot of time and effort to resolve it, and ASCs often do not have the resources to constantly fight these claims. In many cases, this can mean simply not getting paid. This is where effective denial management using predictive analytics comes into play.

Predictive analytics can analyze denial letters to see exactly what the payor requires for resolution. It can then extract these specific data points, prepare them, and submit the claim. This technology can also analyze past claims to pinpoint any systematic issues so the ASC can address them to prevent future denials.

Develop Strategic Payor Negotiations Taking a proactive approach to reducing denials and optimizing reimbursements involves creating solid partnerships with payors. How is that achieved? Through successful payor contract negotiations, aligning with reimbursement models, and producing quality data points.

This is often easier said than done as many ASCs don’t have an advanced data infrastructure. Investing in advanced, AI-driven data analytic platforms are extremely helpful in these cases as they provide indepth insights into operations, payor trends, and patient demographics.

Reduce Denials and Optimize Reimbursement in 2025 Working with leaner margins and smaller administrative teams means ASCs cannot afford to not invest in strengthening their revenue cycle.

And while unique challenges that ASCs face are complicated, they are not insurmountable. Embracing technology, such as automation and predictive analytics, can make a significant difference in ASCs’ financial stability this year.

Patricia Smith is the Director of Revenue Cycle Consulting at SYNERGEN Health. She has more than 20 years of experience leading RCM operations and ASCs with a wealth of experience and specific strategies that offer practical insights for administrators to maximize revenue, minimize denials, and ensure compliance. www.SYNERGENHealth.com BC Advantage Magazine

www.billing-coding.com

13

CURRENT TOPICS IN MAMMOGRAPHY

Mammography remains one of the most critical areas of radiology practice, and one that is facing changes in reporting requirements and reimbursement policy. Even with additional mammography reporting requirements placed on radiology practices, the reimbursement value of mammography services has not changed to reflect the extra work. However, changes to the screening policy could provide increased mammography volume.

14

BC Advantage Magazine

www.billing-coding.com

New Reporting Requirements In March 2023, the FDA issued a Final Rule that went into effect on September 10, 2024, imposing certain specific reporting requirements for mammography results, along with some other quality control measures.

The new reporting requirements that are incorporated into the Mammography Quality Standards Act (MQSA) include: The addition of three new assessment categories in order to more precisely classify findings; A specific timeframe for reporting results when the findings are “Suspicious” or “Highly Suggestive of Malignancy”; and A requirement to include an assessment of breast density. Specifically, •

Changing the wording to be “dense” or “not dense” rather than the high or low-density phrasing in current use.

•

The summary report provided to patients must include specific statements for dense or non-dense findings.

•

The report provided to the patient’s healthcare provider must include an overall assessment of breast density using one of four specific categories.

Breast density assessment is important not only for the patient’s health but it also has reimbursement implications for radiologists. Breast density can often obscure lesions on conventional x-ray mammography, and so other screening modalities such as MRI or ultrasound are often recommended for follow-up. Patients with dense breasts might also require more frequent screening due to their increased risk.

Considerations for Subsequent Imaging Patients identified as having dense breasts are recommended for additional imaging using MRI, ultrasound, or contrast enhanced mammography. Contrast enhanced mammography (CEM) is faster and less costly than MRI and can often be used as a follow-up to an abnormal screening mammogram when it is clinically appropriate.

For the CEM procedure, a diagnostic mammogram is billed as usual along with the addition of a code for the contrast injection (96374), and also for the contrast itself (Q9967) when billing globally or for the technical component.

Note that direct supervision is required for the contrast administration if it is not performed by the physician, and the normal precautions for patients with renal disease or iodine allergies apply. The diagnostic exam typically does not require any additional prior authorization following an abnormal screening exam, whereas using MRI for the follow-up would often require authorization.

While most payors are required to cover traditional screening mammograms for patients who meet the coverage criteria at no out-of-pocket cost to the patient, additional imaging using other modalities might not be similarly covered. There is currently no federal requirement for zero out-of-pocket coverage, but some states have implemented regulations to cover additional imaging, including breast MRI and ultrasound. The status of state coverage is changing quickly, and up-to-date information can be found at the Dense Breast Info website.

At the federal level, the Find It Early Act (H.R. 3086) was introduced in May 2023, and currently has 73 co-sponsors.

It was referred to the House Subcommittee on Health on December 17, 2024. If passed, this bill would require all insurance payors (including Medicare) to cover screening and diagnostic breast imaging with no out-of-pocket costs for women with dense breasts or those who are at higher risk for breast cancer.

Revised Screening Recommendations Radiology practices will benefit from updated recommendations for the initiation of breast cancer screening. In April 2024, the U.S. Preventive Services Task Force (USPSTF) issued a final recommendation statement.

Previously, the USPSTF recommended “that women in their 40s make an individual decision with their clinician on when they should start screening, taking into account their health history, preferences, and how they value the different potential benefits and harms. The Task Force now recommends that all women start getting screened for breast cancer every other year starting at age 40. Basically, it’s a shift from recommending women start screening between the ages of 40 and 50 to recommending that all women start getting screened when they turn 40.”

This is a Grade B recommendation, which means that the Affordable Care Act (ACA) will require most private health insurance plans to cover the screening services without charging patients for deductibles, copayments, or coinsurance.

Conclusion Adequate reimbursement for the level of care provided to patients in this critically important procedure continues to be a challenge. While screening is covered for most patients with no out-of-pocket cost, many need subsequent imaging that is often not fully covered or requires prior authorization that further complicates the overall evaluation process for the patient and radiology practice. We will continue to monitor reimbursement for mammography on both the federal and state level.

Sandy Coffta is Vice President of Client Services at Healthcare Administrative Partners. Coffta has over 17 years of experience in client relationship management, including reimbursement analysis, workflow optimization, and compliance education. www.hapusa.com

BC Advantage Magazine

www.billing-coding.com

15

Data Unveiled The Impact of VBC and AI on Preventive Care and Chronic Disease Management

T

he conversation around chronic disease prevention remains critically important, both for ensuring patient and member health and achieving value-based care (VBC) goals of reducing healthcare costs and improving care quality. The CDC reports in “Chronic Disease Prevalence in the U.S.” that more than 4 in 10 Americans (42%) have two or more chronic conditions, and 12% have at least five, so healthcare stakeholders—from payors and providers to selffunded employers and benefits administrators—are looking for effective ways to address the gaps in preventive care.

Recent analyses of commercially insured patients highlight these challenges, revealing stark deficiencies in preventive care for three of the most common chronic diseases. As reported by Business Wire, data reveals that more than 16

BC Advantage Magazine

www.billing-coding.com

half (53.5%) of women forgo their recommended screening mammograms despite breast cancer being the most common form of cancer. For heart disease, which remains the leading cause of death in the U.S., 31% of working Americans or family members have a cardiac disorder.

Meanwhile, only 35% of COPD and asthma patients receive flu vaccines despite their heightened vulnerability to complications.

These findings highlight an urgent need for a more systematic preventive care approach that integrates advanced analytics and AI-driven predictive capabilities to close these gaps and improve patient outcomes.

The Case for Preventive Care Traditional fee-for-service (FFS) models reward volume and reactive care, which is counterintuitive to preventing disease onset and progression, and does not align incentives between patients, providers, and payors.

Providers could potentially get paid more for latestage disease detection (which requires more intensive and costly care) or unmanaged chronic disease (which requires more frequent encounters with a healthcare system), leading to a perverse incentive system. While many providers do encourage patients to get preventive screenings and vaccinations, and proactively manage chronic diseases, the FFS pay structure doesn’t reward or support these activities. The end result of fee-for-service is an overburdened healthcare system with more sick patients, and increased financial strain on patients and payors.

By contrast, VBC aligns incentives across constituents throughout the healthcare ecosystem, and helps establish reimbursements aligned with patient outcomes.

This benefits patients by focusing on actions that can improve their health over the long term, such as preventive screenings and vaccines. It benefits providers by aligning reimbursement to activities that improve patient health. And preventive care benefits payors as well as patients by minimizing unnecessary spending on emergency department visits, hospitalizations, and latestage disease interventions.

For example, increasing the number of people who get their recommended mammogram screenings can improve outcomes for breast cancer patients by detecting tumors early when there are more options for effective treatment. Similarly, implementing targeted interventions for cardiac patients—identified early through AI-driven risk assessments—could help manage risk factors before they lead to serious events like heart attacks or strokes.

By embedding these strategies into everyday healthcare workflows, providers can improve early detection and help patients manage chronic diseases before they escalate.

Patients, providers, and payors benefit from this shift, as improved health outcomes translate to lower long-term costs and better quality of life for individuals managing chronic conditions.

The Role of AI-Driven Analytics in Strengthening Preventive Care AI is changing the way healthcare stakeholders approach preventive care by uncovering deeper insights into patient risk factors and improving care coordination.

Advanced predictive models powered by AI facilitate targeted interventions for some of the costliest chronic diseases, enabling large-scale risk reduction by delaying or avoiding disease onset, and slowing disease progression. However, to be effective, AI predictive models must have robust underlying analytics and a large pool of anonymized patient data from which to learn and improve predictive capabilities over time. As AI capabilities increase, these tools are critical to assist providers and payors in optimizing outcomes, reducing costs, and addressing care gaps.

Today’s most advanced machine learning algorithms are capable of identifying individuals at high risk for chronic disease diagnosis in the coming year. These AI tools expand analytics capabilities beyond traditionally used rules-based logic, enabling analysis of a much wider range of metrics—including claims history, biometric screenings, and other health indicators—to detect potential cases that would otherwise have fallen below conventional diagnostic thresholds. Continuous collaboration between data scientists and clinical teams ensures the validation and improvement of these models.

AI can also optimize resource allocation by targeting preventive care efforts where they are needed most. For instance, health systems can use AI to direct resources toward populations with low screening rates, improving outreach and follow-up while reducing costs.

As the use of AI tools grows in healthcare, it’s also critical that companies developing these tools maintain the highest standards for data security and patient privacy, ensuring the responsible use of technology in advancing care. The stakes are high in healthcare, where users are dealing with patient lives. AI development must include robust testing to eliminate bias and error, and should never be intended as a replacement for the skill and knowledge of care providers. Instead, it should be a tool to augment providers’ capabilities to offer the right care, at the right time, in the right place.

BC Advantage Magazine

www.billing-coding.com

17

Breaking Barriers to Preventive Care Adoption Despite the clear benefits of preventive care, several challenges remain to get every patient the care they need.

One major barrier is patient non-engagement, as many people delay or skip recommended screenings due to a lack of awareness, logistical hurdles (such as limited access to convenient and ongoing care), or financial concerns.

Employers and insurers can help address these obstacles by offering incentives for preventive care adherence and expanding access to affordable and accessible care based on population needs. For example, if analytics reveals low flu vaccination rates in a specific geographic area, an organization could use that information to launch targeted mobile vaccine clinics in the area.

Health literacy is also an issue, as many patients remain unaware of the importance of early screenings or may not fully understand their own risk factors for chronic disease. Expanding outreach efforts and simplifying access to preventive care services—such as mobile-friendly scheduling, virtual consultations, and workplace health programs—can help bridge this gap.

Another significant challenge is the administrative burden on providers, who are stretched thin and may struggle to prioritize preventive care within their workflows.

Fragmented patient data contributes to this burden, forcing providers and care teams to navigate multiple systems and formats to identify the patients with preventive care needs. Enterprise data management systems with advanced interoperability capabilities can help by unifying information from EHRs, claims data, and other sources, reducing silos and manual work. AI-driven insights further support providers by quickly sorting through all the available data to pinpoint the most pressing patient needs, streamlining decision-making, and improving care.

Aligning for Action: The Future of Preventive Care A collaborative approach is essential to a value-based future where preventive care takes center stage. Employers, payors, and providers must work together to increase preventive measures, leveraging AI and predictive analytics to identify high-risk individuals. Health plans and employer wellness programs can encourage patient adherence to screenings

18

BC Advantage Magazine

www.billing-coding.com

and vaccinations with appropriate incentives. At the same time, providers can use AI-driven risk stratification to tailor interventions to individual patient needs.

Ultimately, the success of preventive care strategies depends on a shift in mindset across the healthcare industry. Instead of waiting for patients to present with advanced disease, we must proactively identify at-risk populations and engage them in their healthcare journeys early. The integration of AI and VBC technology makes this possible.

As the healthcare industry navigates evolving value-based care models, embracing a more proactive, technologydriven approach to preventive care will be critical. AI-driven insights and VBC incentives provide a clear pathway for closing the gaps in early detection and chronic disease management, leading to a healthier population, lower costs, and a more sustainable healthcare system.

David L. Morris is EVP and Chief Commercial Officer at Cedar Gate Technologies. He has over 30 years of operational and executive leadership experience at blue-chip companies throughout the healthcare ecosystem. David drives client success across the value-based healthcare landscape by addressing the technology and service needs of the payor, provider, employer, pharma, and retail markets. He serves as Chief Commercial Officer with oversight of all commercial efforts, including market strategy, sales, and client success management.

Prior to joining Cedar Gate, David held key leadership roles as EVP and Chief Commercial Officer with Citra Health Solutions, Chief Revenue Officer with Eliza Corporation (acquired by HMS Holdings), Senior Vice President of Global Sales and Services with Bupa Health Dialog (acquired by Rite Aid), National Vice President of Healthcare for SAP America, IMS Health (acquired by IQVIA), Baxter and George Washington University (GWU) Medical Center. https://www.cedargate.com

BC Advantage Magazine

www.billing-coding.com

19

THE MAY 12, 2025 U.S. DEPARTMENT OF JUSTICE MEMO:

WHAT THE HEALTHCARE INDUSTRY SHOULD KNOW

O

n May 12, 2025, the U.S. Department of Justice (DOJ), Head of the Criminal Division, released a memorandum, “Focus, Fairness, and Efficiency in the Fight Against White Collar Crime” (see https://www.justice. gov/criminal/media/1400046/dl?inline). The first sentence states, “The core mission of the Department of Justice (Department) is to do justice, uphold the rule of law, protect the American public, and vindicate victims’ rights.”

As updated in September 2024, the DOJ Criminal Division’s “Evaluation of Corporate Compliance Programs” is equally as important to read as the May 12 memo. A couple of notable items include: (1) three “fundamental questions” prosecutors should ask; (2) “assessing whether the [compliance] program is adequately designed for maximum effectiveness”; and (3) management of emerging risks to ensure compliance with 20

BC Advantage Magazine

www.billing-coding.com

applicable law. A good starting point for implementing a new compliance program or revising an existing program is 42 CFR § 483.85.

As the U.S. Department of Health and Human Services Office of the Inspector General (HHS-OIG) has stated for years and re-emphasized in its November 2023 Compliance Guidance, the five main fraud, waste, and abuse laws (FWA) are as follows: (1) False Claims Act; (2) Anti-Kickback Statute; (3) Stark Law; (4) Exclusion; and (5) Civil Monetary Penalties.

These five FWA laws are relevant to the May 2012 memo.

What follows are some of the key highlights that companies, executives, and boards alike need to address and incorporate into their enterprise risk management (ERM) program.

Analysis The Cybersecurity Infrastructure and Security Agency (CISA) identified 16 critical infrastructure sectors, including the Health and Public Health Sector, targeted by cyber criminals, which harm the federal fisc and United States citizens as a whole.

The “areas of focus” identified by the DOJ as being the most “urgent criminal threats to the country” include a variety of conduct. At the top of the list is “waste, fraud, and abuse, including healthcare fraud and federal program and procurement fraud that harm the public fisc” (emphasis added).

Other areas include, but are not limited to:

Conclusion Government enforcement actions are not receding when it comes to the aforementioned areas of focus. To the contrary, with greater scrutiny comes the need for greater board governance and adequate compliance programs.

Three prudent steps to mitigate risk include: 1

Review existing cybersecurity laws and regulations and ensure that an annual risk analysis is conducted.

2

Ensure compliance programs are updated and that all seven core items required by 42 CFR § 483.85 are implemented.

3

Train boards and executives to issue spot, understand industry and cyber vernacular, and recognize potential areas of FWA and criminal liability that relates to the business.

Trade and customs fraud, including tariff evasion; Conduct that threatens the country’s national security, including threats that harm the U.S. financial system; Fraud that victimizes U.S. investors, individuals, and markets including, but not limited to, Ponzi schemes, investment fraud, elder fraud, servicemember fraud, and fraud that threatens the health and safety of consumers; and Violations of the Controlled Substances Act and the Federal Food, Drug, and Cosmetic Act (FDCA), including the unlawful manufacture and distribution of chemicals and equipment used to create counterfeit pills laced with fentanyl and unlawful distribution of opioids by medical professionals and companies.

Armed with this knowledge, organizations, executives, and boards should commit to doing the following: (1) audits— cybersecurity, financial, and FWA; (2) adequate and ongoing training; (3) comprehensive policies and procedures; (4) encryption both at rest and in transit; and (5) adequate data use agreements, business associate agreements, or other similar agreements. Being able to substantiate an effective and adequate compliance program is critical for mitigating liability.

Rachel V. Rose, JD, MBA, (Houston, Texas) is a disciplined, empathetic, and tenacious attorney advocating for and winning desired legal outcomes for national and international clients. Ms. Rose’s practice includes compliance, transactional, and litigation matters primarily related to healthcare, cybersecurity, securities, the False Claims Act, and Dodd-Frank. She is also affiliated with Baylor College of Medicine where she teaches bioethics. ​Ms. Rose is an attorney with a history of being first: 1. First False Claims Act settlement under the U.S. Department of Justice’s Civil Cyber Fraud Initiative, 2. First woman to chair the Federal Bar Association’s Government Relations Committee, 3. First attorney to be featured on the Becker Group Women’s Leadership 15 Minute Podcast, 4. First 1st Healthcare Compliance Presenter to be recognized as “Presenter of the Year” twice (2019, 2022). www.rvrose.com

BC Advantage Magazine

www.billing-coding.com

21

THE REIMBURSEMENT PLATEAU BREAKING THROUGH THE LIMITS OF TRADITIONAL RCM

P

roviders today face increasing pressure, especially when outdated revenue cycle management (RCM) is hindering their financial and operational performance.

Collections from insured patients have fallen from 37.6% in 2023 to 34.4% in 2024 (as reported by techtarget.com), highlighting a growing gap between effort and revenue.

Inefficient reimbursement processes are a major culprit, consuming valuable administrative resources, delaying crucial payments, and jeopardizing practice cash flow.

The Persistent Problems With Traditional RCM Systems Traditional RCM systems rely heavily on manual processes, including paper checks, ACH transactions, and separate handling of electronic remittance advices (ERAs/835 files). Although ACH payments are sometimes seen as an improvement over paper checks, they fail to ease the administrative load because they cannot carry crucial HIPAAcompliant patient remittance data.

So, providers are often left to manually re-associate payments with patient claims. This inefficiency delays reimbursements and creates unnecessary complexity and potential inaccuracies. Ongoing healthcare staffing shortages exacerbate these challenges. Every moment spent manually reconciling payments or hunting down missing patient data is time away from critical patient-facing responsibilities, amplifying pressures already felt across the healthcare industry.

22

BC Advantage Magazine

www.billing-coding.com

The reality for many practices is daunting. Staff members spend hours each week manually sorting through paper checks, keying in data, and verifying claim information.

The workload continues to grow, further burdening already strained teams and worsening inefficiencies.

Why ACH Isn’t a Complete Solution While ACH transfers are a digitized step forward from paper checks, they remain inadequate for modern healthcare needs. ACH lacks the capability to transmit essential HIPAA-sensitive patient information, leading to further manual interventions. The banking system simply wasn’t built to handle this data: Nacha formats lack sufficient space and HIPAA regulations weren’t designed to make banks compliant entities, leaving little-to-no business value for them in handling healthcare-specific remittance content.

Thus, banks and other financial institutions intentionally steer clear of handling detailed healthcare remittance data due to compliance concerns, leaving providers to continue to bridge the gap through painstaking manual reconciliation.

Additionally, while more streamlined than paper checks, ACH payments still carry inherent speed and reliability limitations. Transactions can take several days to process, delaying cash flow and limiting visibility into the transaction lifecycle. This delay can severely disrupt a practice’s ability to plan financially, making budgeting and resource allocation challenging.

The Power of Next Generation Payment Rails The next generation of digital payment rails offers a clear, powerful path forward, merging sensitive patient data with financial data for the first time. Unlike ACH, these advanced digital rails are natively HIPAA-compliant and have the storage to embed detailed remittance data directly within transactions, which supplies healthcare providers with immediate, automated reconciliation. Where ACH is a partial step forward, fully digitizing and digitalizing transactions onto next generation payment rails is poised to significantly reduce the time spent matching payments to claims, dramatically decrease accounts receivable (A/R) days, and shrink reimbursement processing from a multi week process to mere days.

Back-end impact is valuable. These streamlined systems automatically post reimbursements directly into practice management systems (PMSs) or electronic medical records (EMRs), eliminating manual data entry and reducing costly errors. In fact, automated claims processing slashes manual work by up to 95% (thoughtful.ai). Additionally, digital payment rails can deliver instant notifications and provide clear, consistent reporting across all payors, enhancing the financial visibility and control providers have long needed.

For example, envision a dental practice with 15 staff who are working overtime, yet still struggle with these payment functions. Manual, burdensome tasks such as processing stacks of insurance checks and matching payments to checks by hand is a common experience. Instead, new technologies enable the automation of check processing paired with remittance data in a centralized, intuitive platform.

Accelerating Patient Collections and Revenue Management Beyond merely faster payments, digitizing payor reimbursements also equips practices to rapidly identify patient financial responsibility, accelerating patient collections and improving overall revenue health. Providers no longer wait days or weeks to bill patients for outstanding balances; the information is available almost instantly after the payor’s payment clears.

This capability fundamentally changes the patient billing experience. Nearly half (40%) of patients prefer their healthcare providers to offer contactless and online portal payments, often due to detailed billing, cost estimates, payment options (card-on-file, test-to-pay, etc.), insurance information, and communication tools (reported by pymnts. com). Instead of confusion and delays, patients receive

the timely, accurate invoices reflecting their true financial responsibility. This clarity enhances patient satisfaction and increases the likelihood of prompt payments, improving overall cash flow for the practice, and completing the entire RCM process.

Real-World Impact and Results Early adopters of these digital payment rails have seen measurable improvements in their operations. Practices report up to 25% reductions in A/R days, directly boosting their available working capital and allowing them to invest in other critical areas such as patient care, technology upgrades, or staffing.

Providers also see administrative time savings, often reclaiming several hours previously spent on manual reconciliation tasks each week. This reclaimed time can be redirected to essential patient-facing activities, improving overall patient care and satisfaction.

Building Lasting Financial Health Going all-in on digital, integrated reimbursement solutions does much more than speed things up; it fundamentally changes how healthcare practices manage their money.

Providers who utilize these tools gain a powerful understanding of their financial situation, allowing them to make smart decisions ahead of time. This financial adaptability builds stronger stability and the ability to withstand market ups and downs and industry pressures.

With the healthcare world constantly facing new challenges, from changing regulations to staffing issues, providers who adopt cutting-edge RCM technologies will stay ahead of the curve. Digital payments set up healthcare practices to not just get by, but to truly thrive, ultimately supporting lasting financial health and better patient care.

Matthew Bernier serves as Product Management Director and VP for PayerSync at Rectangle Health, leading agile teams focused on building high-impact integrations and functionality across patient payments, engagement, and compliance. With over 15 years in healthcare technology and payer operations, Matthew has held product roles at Immediata, McKesson, Centene, and Elevance Health, where he honed deep expertise in payer-provider dynamics and claims processing. www.rectanglehealth.com BC Advantage Magazine

www.billing-coding.com

23

Understanding and Defending Against ZeroPaid Healthcare Claims

I

n the complex world of insurance and healthcare claims, the concept of “zero-paid claims” can feel like a phantom menace. You’ve submitted a claim, received an Explanation of Benefits (EOB) or remittance advice, and to your dismay, the payment is… zero. While a zero payment might seem innocuous, it can, in certain scenarios, be interpreted by payors as a lack of valid claim submission, potentially leading to the exclusion of those services from future considerations, such as bundled payments, quality metrics, or even appeals. This can have significant financial repercussions for healthcare providers, making it crucial to understand why zero-paid claims occur and, more importantly, what proactive steps you can take to defend against their exclusion.

Why Do Zero-Paid Claims Occur? Understanding the Root Causes Before we dive into defense strategies, let’s unpack some of the most common reasons why a claim might be “zero-paid”: 24

BC Advantage Magazine

www.billing-coding.com

Deductibles and Coinsurance: This is perhaps the most straightforward reason. The patient’s deductible hasn’t been met, or the payment is fully attributed to their coinsurance responsibility. While the payor isn’t paying you, they are acknowledging the service.

Services Not Covered: The service billed may not be a covered benefit under the patient’s plan. This could be due to specific exclusions, experimental procedures, or services deemed not medically necessary.

Duplicate Claims: You might have accidentally submitted the same claim twice, and the payor has processed and zero-paid the duplicate.

Timely Filing Limits: The claim was submitted past the payor’s timely filing deadline.

Incorrect Billing or Coding: Errors in CPT codes, ICD-10 codes, modifier usage, or patient demographics can lead to a zero payment as the claim is unprocessable as submitted.

is your first and strongest line of defense against any claim dispute, paid or zero-paid.

Lack of Prior Authorization: For certain services, prior authorization is mandatory. If it wasn’t obtained, or if the authorized service differs from the one billed, a zero payment can result.

Precise Coding: Train your coding staff to the highest standards. Regularly audit coding practices to catch errors in CPT, ICD-10, and modifier usage. A correctly coded claim, even if zero-paid due to patient responsibility, is a correctly processed claim in the payor’s system.

Bundled Services: The service might be considered inclusive within a larger, already-paid service, and therefore not separately reimbursable.

Medical Necessity Denials: Even if a service is technically covered, the payor may deny it based on a lack of medical necessity, resulting in a zero payment.

The key takeaway here is that not all zero-paid claims are created equal. Some represent a legitimate processing of the claim, while others indicate an issue that needs to be addressed. The challenge arises when payors selectively acknowledge some zero-paid claims but not others for downstream purposes.

Accurate Patient Demographics and Insurance Information: Verify patient insurance eligibility and benefits at every visit. Even a minor typo in a subscriber ID can lead to a claim being processed incorrectly or zero-paid.

2

Electronic Claim Submission (EDI): Utilize EDI whenever possible. This provides an electronic trail of submission and confirmation. Keep records of your EDI transmission reports.

The Threat of Exclusion: Why Zero-Paid Claims Matter

Proof of Timely Filing: For claims submitted via paper (rare, but still occurs), always use certified mail with a return receipt or a similar method that provides verifiable proof of delivery and date.

The real danger of zero-paid claims lies in the potential for payors to exclude them from calculations that directly impact your revenue and operational efficiency. Imagine a scenario where a payor is calculating your performance for a bundled payment program. If they decide to exclude all services for which they made no payment, even if the service was legitimately provided and documented, it can artificially deflate your case mix, reduce your target payment, or negatively impact your quality metrics.

Similarly, during an audit or an appeal process, a payor might argue that a zero-paid claim was never “properly submitted” or “processed” in a way that validates the service.

This can undermine your ability to justify the care provided or to contest a subsequent denial.

Proactive Defense: Steps to Safeguard Your Claims Defending against the exclusion of zero-paid claims requires a multi-faceted, proactive approach: 1

Meticulous Documentation and Billing Accuracy Comprehensive Clinical Documentation: Ensure that every service provided is thoroughly documented in the patient’s medical record. This includes clear indications for services, detailed descriptions of procedures, and accurate recording of diagnoses. Robust documentation

Robust Claim Submission and Tracking Protocols

Centralized Claim Tracking System: Implement a system to track every claim submitted, its submission date, and its current status (pending, paid, zero-paid, denied). This allows you to quickly identify zero-paid claims and initiate follow-up.

Monitor Remittance Advice/EOBs: Don’t just file away zero-paid EOBs. Analyze them. Understand why the claim was zero-paid. Is it a deductible? A non-covered service? This analysis informs your next steps.

3

Strategic Follow-Up and Appeals Categorize Zero-Paid Claims: Develop a system to categorize your zero-paid claims based on the reason for the zero payment. This helps you prioritize which claims require further action.

Follow Up on Actionable Zero-Paid Claims: For zeropaid claims due to preventable errors (e.g., timely filing, incorrect coding), correct the error and resubmit the claim promptly. This demonstrates your effort to achieve proper claim processing.

BC Advantage Magazine

www.billing-coding.com

25

Appeal Incorrect Zero-Paid Claims: If you believe a zero-paid claim was incorrectly processed (e.g., medical necessity denial for a covered service), initiate an appeal. Even if the appeal results in another zero payment, the appeal process itself creates a documented trail of your efforts to validate the service.

Maintain Records of All Correspondence: Keep detailed records of all communication with payors regarding zero-paid claims, including phone calls (date, time, representative name, summary of discussion), written correspondence, and appeal documents.

4

Proactive Payor Communication & Contract Review Understand Payor Policies: Regularly review payor policies, medical policies, and billing guidelines. Stay informed about changes that could impact how claims are processed, especially those related to bundled services or medical necessity.

Engage with Payors Regarding Zero-Paid Claim Interpretation: If you notice a trend of zero-paid claims being excluded from your performance metrics, initiate discussions with your payor representatives. Seek clarification on their policies regarding the inclusion/ exclusion of zero-paid services in various programs. Get these clarifications in writing.

Review Payor Contracts Carefully: Pay close attention to contract language regarding claim submission, payment, and the definition of “processed claims.”

If possible, advocate for language that explicitly acknowledges zero-paid claims as validly processed claims when certain conditions are met (e.g., patient responsibility).

5 Leverage Technology and Analytics Reporting and Analytics Tools: Utilize your practice management system or third-party analytics tools to generate reports on zero-paid claims. Identify trends by payor, service, or patient demographic. This data is invaluable for identifying systemic issues.

26

BC Advantage Magazine

www.billing-coding.com

Revenue Cycle Management (RCM) Software: Invest in robust RCM software that can automate claim scrubbing, denial management, and reporting, helping you to proactively manage zero-paid claims.

Conclusion The exclusion of zero-paid claims is a subtle yet significant threat to the financial health of healthcare providers.

By understanding the reasons behind zero payments, implementing meticulous documentation and medical billing practices, maintaining robust tracking systems, engaging in strategic follow-up and appeals, and fostering proactive communication with payors, you can build a formidable defense. Don’t let your valuable services be silently excluded from the calculations that define your practice’s success. Take these steps today to ensure every claim, paid or zero-paid, properly reflects the care you provide.

Allzone, established in 2005, is a leading offshore medical billing company that provides medical billing, coding, and RCM (revenue cycle management) services to clients nationwide. The Allzone team possesses an in-depth understanding of today’s markets, allowing us to better develop a long-term macroeconomic perspective. From here, its consistent quality, innovative delivery methods, and competitive pricing that matter the most. Creating customized solutions that are tailor-made for each customer’s requirement sets Allzone apart from the crowd. https://www.allzonems.com/

BEST PRACTICES TO OVERSEE YOUR BILLING AND COLLECTIONS:

A PRACTICAL FRAMEWORK FOR BEST PRACTICES TO REAL-WORLD OVERSIGHT

OVERSEE

YOUR BILLING

AND COLLECTIONS

28

BC Advantage Magazine

www.billing-coding.com

Your revenue cycle isn’t just a back-office function, it’s the financial backbone of your organization.

Yet many practices still rely on high-level snapshots like monthly charges and deposits to evaluate billing performance. That reactive approach often leaves revenue issues undetected until they’ve grown too large to ignore.

Oversight doesn’t require complicated analytics or expensive software. It starts with monitoring a handful of accessible metrics that give you real-time insight into where your money is moving—and where it’s stalling. Whether you’re a provider, administrator, or billing leader, these five weekly checkpoints will give you the clarity you need to take action before small issues become major problems.

Here are five key metrics that should be reviewed weekly to gain insight into how your revenue cycle is really functioning: Total charges vs. payments posted Deposit and posting variance Adjustment activity review A/R movement and variance Front desk performance and collections You may already be tracking some or all of these metrics, but how you track them matters just as much as whether you do.

Using the wrong reports, overly generalized categories, or inconsistent timeframes can lead to misleading conclusions and

BC Advantage Magazine

www.billing-coding.com

29

missed opportunities. These metrics are only valuable when they’re evaluated with clarity, consistency, and a focus on root cause.

Let’s break each one down and discuss what it tells you, and why it matters.

Total Charges vs. Payments Posted This metric offers an essential comparison of the work your practice is doing (charges) against what you’re being paid for (payments). Reviewing this weekly helps identify mismatches that could indicate claim holds, payor slowdowns, or workflow gaps.

By reviewing by date of service, we can assess the financial performance and payment trends of services delivered during a specific time period. This view helps isolate where revenue is delayed or missing entirely, and over time, it also reveals the average percentage of charges that your practice is actually collecting. This is critical for setting realistic cash flow expectations and spotting payor or process inconsistencies.

By reviewing by posting date, we can monitor when payments are actually hitting your system, which helps flag slowdowns in payor processing or internal posting backlogs.

This perspective complements the date of service view by reflecting actual revenue movement.

In addition, reviewing both views may reveal patterns around specific services, CPT combinations, or modifiers that consistently lead to payment delays due to additional payor review. Recognizing these trends helps your billing team proactively refine workflows, educate providers on documentation standards, and avoid repeated rework on the same types of claims, ultimately supporting a cleaner, faster reimbursement process.

30

BC Advantage Magazine

www.billing-coding.com

Monitor for Deposit & Posting Variance If you aren’t actively reviewing a report that compares what was deposited daily to what was posted daily, chances are this reconciliation process isn’t being done. And when it isn’t, it becomes far too easy to miss payment posting errors, overlooked deposits, or worse—revenue leakage and misconduct. Reconciliation ensures every EFT, mailed check, and in-office payment, regardless of the number of deposits generated per day, is accurately balanced and appropriately reflected in your system.

Not balancing daily means your organization is not truly accounting for all the monies received in a day’s time. And if there’s no regular monitoring to ensure that reconciliation is occurring, then it likely isn’t. This isn’t just a gap in process, it’s a risk to your organization. Without weekly oversight of this daily process, there’s no way to verify that deposits are being handled correctly, that payments are being recorded accurately, or that all revenue is making its way into your system. This opens the door to operational problems, delayed revenue, and potential integrity concerns that could enable inappropriate behavior involving both cash and noncash payments.

Adjustment Activity Review Adjustments are literally writing off work your practice has performed, either as reduced reimbursement or as completely non-reimbursable. Yet surprisingly, they’re often one of the least monitored metrics in the revenue cycle. In many practices, the billing team uses a single write-off code labeled “Insurance Adjustment” across the board, regardless of the reason for the adjustment. This broad categorization creates a serious reporting blind spot, preventing oversight into where and why revenue is being lost, and reducing accountability across teams.

To properly monitor adjustments, practices must move beyond a single write-off code. Every adjustment should be tied to a specific, non-contractual reason code that accurately reflects why it occurred. Having this level of distinction allows for true oversight and reporting capabilities based on the cause of revenue loss, whether it’s a timely filing issue, a medical necessity denial, a

professional courtesy write-off, or an out-of-network service.

This categorization supports more accurate financial reporting, easier audit trails, and actionable performance insights.

When this isn’t in place, not only is your data inaccurate, it’s also nearly impossible to audit. Reviewing adjustment activity weekly allows for a proactive response to patterns of avoidable revenue loss, flags internal posting inconsistencies, and ensures you’re not routinely writing off dollars that could have been recovered with better documentation or follow-up.

If your weekly reports don’t provide a breakdown of adjustments, or if nearly every adjustment falls under a general label, it’s a clear sign your billing process needs restructuring.

Monitoring Variance in A/R Accounts Receivable (A/R) is where your revenue sits until it’s collected or written off, and too often, practices track the total but not the trend. Monitoring weekly variance in A/R helps you understand whether outstanding balances are increasing, decreasing, or stagnating. But it’s important

to recognize that there is no universal “ideal” A/R number.

Chasing a target A/R value without understanding what’s behind it can lead to harmful practices, such as inappropriate or premature write-offs just to reduce the reported total.

Instead, focus on trends and variances that reflect your actual operational performance. This oversight is key to evaluating the effectiveness of your collection efforts, including both insurance follow-up and patient responsibility.

By reviewing A/R movement by payor, age, and provider, you can catch early signs of delays, identify gaps in follow-up workflows, and ensure high-balance accounts aren’t being ignored. Many organizations wait until A/R has reached critical levels before they invest in a billing audit, provisional resourcing, additional staffing, or PM system improvements. By then, the issue has already affected cash Accounts Receivable (A/R) is where your revenue sits until it’s collected or written off, and too often, practices track the total but not the trend.

Monitoring weekly variance in A/R helps you understand whether outstanding balances are increasing, decreasing, or stagnating. But it’s important to recognize that there is no universal “ideal” A/R number. Chasing a target A/R value without understanding what’s behind it can lead to harmful practices, such as inappropriate or premature write-offs just to reduce the reported total. Instead, focus on trends and BC Advantage Magazine

www.billing-coding.com

31

variances that reflect your actual operational performance.

This oversight is key to evaluating the effectiveness of your collection efforts, including both insurance follow-up and patient responsibility.

continuous analysis of front desk performance, you can identify training needs, address gaps in processes, and reinforce that the front desk is not separate from RCM—it is the starting line.

By reviewing A/R movement by payor, age, and provider, you can catch early signs of delays, identify gaps in followup workflows, and ensure high-balance accounts aren’t being ignored. Many organizations wait until A/R has reached critical levels before they invest in a billing audit, provisional resourcing, additional staffing, or PM system improvements. By then, the issue has already affected cash flow, and efforts to course-correct often become reactive.

Monitoring weekly prevents you from playing Friday night quarterback, trying to explain an exponential rise that could have been addressed weeks earlier. If your A/R is growing without explanation, or shrinking due to write-offs instead of true collections, it’s a clear sign to investigate both your process and your follow-up performance.

Don’t assume point-of-service collections and accurate data capture are happening just because a policy exists. Monitor the data, and act on what it tells you.

Front Desk Collection Totals (Copays, Balances) The revenue cycle begins long before a claim is submitted; it starts the moment patient information is entered into your system. That’s why your front desk team plays a critical role in both the financial and operational success of the practice. Yet, front desk performance is rarely analyzed as part of the RCM strategy.

Monitoring what’s collected at the point of service, copays, deductibles, and balances is one of the most immediate and impactful ways to reduce A/R and support cash flow.

Patients are most likely to pay when they’re in the office, and front desk staff should be empowered to collect with clear expectations and support from their providers.

Physicians should reinforce these efforts by backing up financial policies with their patients.

But collections are just one part of the picture. Repeated errors in demographic or insurance data entry result in claim denials that the billing team cannot control, creating rework, delays, and revenue leakage. Weekly monitoring helps leadership assess not only what’s being collected, but also how consistently front-end processes are being executed.

If collection totals are low or vary significantly by day, location, or staff member, that may indicate unclear policies, insufficient training, or system limitations. By performing 32

BC Advantage Magazine

www.billing-coding.com

Why This Matters Too many practices evaluate their billing based on how the bank account feels. But if you wait for revenue trends to show up in your deposits, you’re already weeks behind the problem.

Instead, these weekly metrics offer a more timely, tactical look into what’s really happening in your revenue cycle. They’re accessible, actionable, and essential to creating financial stability.

So, the question becomes: What are you monitoring— and how often?

If you’re relying on month-end reports or broad overviews, it’s time to dig deeper. The goal is not just to collect revenue; it’s to manage it, measure it, and make it predictable.

Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CMPM, CPMN, is the Director of Coding and a partner at DoctorsManagement, as well as the founder and president of NAMAS. Shannon brings more than 16 years of multi-specialty auditing and coding experiences to DoctorsManagement clients, helping practices optimize business processes and maximize reimbursements. https://namas.co www.doctors-management.com

One Subscription.

Endless CEUs.

Zero Fluff.

FREE 4 Week Trial with 4 FREE CEUs Subscriptions starting as low as $15 per month for 24 annual CEUs BC Advantage Magazine

www.namas.co 33 namas@namas.co

www.billing-coding.com

Healthcare Awareness Spotlight July is UV Awareness Month It’s the middle of summer, so it seems appropriate that it is UV Awareness Month!

Dermatologist Recommendations: Clothing and Accessories

Whether by the pool, hitting the hiking and biking trails, or simply gardening this summer, it is important to remember that both ultraviolet A (UVA) and ultraviolet B (UVB) rays from the sun are harmful to the human bodies’ largest organ—the skin. In fact, skin cancer is the most common cancer in the United States, affecting one in five Americans by the age of 70.

Top dermatologists in the nation uniformly offer five recommendations for effective sun protection.

But there are many ways to protect our skin year-round and not become a statistic. According to the American Academy of Dermatology Association, the best way to do this is by seeking shade when appropriate, wearing sun-protective clothing, and applying a broad-spectrum, water-resistant sunscreen with an SPF of 30 or higher.

34

BC Advantage Magazine

www.billing-coding.com

These recommendations include: 1

Wear dark-colored, lightweight, long-sleeved shirts and pants.

2

Wear clothing with an ultraviolet protection factor (UPF) marked on the label.

3

Wear large-frame sunglasses with dark lenses and UV protection.

4

Wear wide brimmed hats protecting ears, head, and neck.

5

Wear shoes that cover your feet.

6

Throw out old, expired sunscreen. The Food and Drug Administration (FDA) requires sunscreens to maintain their efficacy for three years from the date of purchase.

7

Use sun-protective clothing and accessories in addition to sunscreen.

Skin Cancer Facts Unfortunately, neglecting or using inadequate skin protection risks serious consequences.

Sobering facts from the Skin Cancer Foundation: One out of every five Americans will develop skin cancer by the age of 70.

More than two people die of skin cancer in the United States every hour.

Having five or more sunburns doubles the risk of melanoma.

UV Awareness and Education

Dermatologist Recommendations: Sunscreen When it comes to sunscreen, it helps prevent sunburns and skin cancer, as well as premature skin aging, including wrinkles and age spots. However, dermatologists continue to advise their patients on matters involving effectiveness.

Here are some reminders: 1

Use broad-spectrum (UVA and UVB), water-resistant sunscreen with an SPF of 30 or higher.

2

Use enough. Apply one ounce of sunscreen to fully cover areas of skin not covered by clothing or shoes.

3

Apply 15 minutes before going outdoors.

4

Reapply one ounce of sunscreen every two hours while outdoors, sweating, or swimming.

5

Let’s take action this July and continue promoting UV awareness and education to protect our skin and eyes from the sun’s harmful rays. Remember, you can always step aside and enjoy summer under the shade of large trees, beach umbrellas, and park pavilions or gazebos.

Enjoy summer with all the protection you need!

For more information, visit the resources cited herein: Skin Cancer Foundation (skincancer.org) and the American Academy of Dermatology (aad.org).

Sonal Patel, BA, CPMA, CPC, CMC, ICDCM, is CEO and Principal Strategist of SP Collaborative, LLC. Sonal has over 13 years of experience understanding the art of business medicine as a nationally recognized thoughtleader, speaker, author, creator, and consultant to elevate coding compliance education for the business of medicine. www.spcollaborative.net

Use sunscreen outdoors, even on cloudy days.

BC Advantage Magazine

www.billing-coding.com

35

Optimize Your Billing and Payments Workflow Three Ways to Improve Efficiency and Reduce Waste

O

perational efficiency is no longer nice to have in today’s healthcare environment—it’s a must.

Staffing shortages, evolving regulations, and tighter reimbursement margins mean organizations can no longer afford to leave money—or time—on the table. One of the most impactful places for healthcare organizations to start is their billing and payments workflow.

Streamlining billing isn’t just about getting paid faster. It’s about reclaiming hours, reducing errors, and freeing up staff to focus on what truly matters: patient care. The good news is that optimizing workflows to unlock those benefits is simpler than you might think.

RXNT has seen firsthand how simple changes enable organizations to create more modern workflows. One client lowered billing time by over 650 hours every month. Another shaved off three hours of billing work per provider—a dramatic difference for organizations managing multiple providers. So, how can your organization achieve similar results?

Below, you’ll learn three key areas where optimizing your billing and payments workflow can help you unlock a greater ROI. 36

BC Advantage Magazine

www.billing-coding.com

Streamlining Charge Capture and Payment Collection Charge capture and payment collection may seem like basic operational tasks, but they’re often riddled with inefficiencies that cost practices a significant amount. In fact, inaccurate or delayed charge capture is one of the leading causes of revenue leakage in medical practices, with studies estimating that hospitals can lose 1% in potential revenue due to charge capture problems alone (Aspirion. com).

Some of the most common pitfalls around charge capture include: Delayed documentation: When providers document service hours or even days after a patient encounter, key details can be forgotten, leading to undercoding or missing charges entirely.

Inconsistent coding: Without standardized processes or checks, different providers may use varying codes for the same services, creating billing confusion and increasing the risk of denials.

Manual processes: Paper-based or fragmented digital systems often result in charges being entered multiple

times (and inconsistently), increasing staff workload and the chance for errors.

Lack of visibility: Practices often struggle to track the status of charges across departments or team members, slowing down reimbursements and obscuring revenue performance.

Implementing a modern, integrated charge capture system ensures that every service rendered is accounted for in real time. By removing manual steps and giving providers tools to document charges at the point of care, practices reduce delays, improve accuracy, and speed up payment collection.

Limited visibility into denied or underpaid claims slows down appeals and keeps practices in the dark about payor performance.

To stay profitable and efficient, practices must modernize how they manage insurance payments. That means implementing tools that provide real-time warnings, autosave, and keyboard shortcuts to minimize disruptions and reduce posting time.

By optimizing this part of the workflow, practices can: Reduce denied or misapplied payments.

Accelerate collections and reimbursements.

That’s where tools like RXNT’s Charge Capture App can make a meaningful difference. It gives providers and staff mobile access to record patient services quickly and assign codes directly from a smartphone or tablet. Once those codes are entered, they flow into RXNT’s cloud-based billing solution for streamlined processing, eliminating data silos and improving accuracy.

Unlocking Data Insights for Better Billing Decisions

Insurance Payments: Where Accuracy Drives Revenue

Many practices struggle with limited reporting capabilities, leading to reactive decisions and missed opportunities for revenue growth.

Insurance payment posting can feel like navigating a maze—especially when working across multiple payors with different rules, reimbursement rates, and claim formatting.

Unfortunately, even small posting errors can snowball into thousands of dollars in lost revenue and hundreds of hours of rework.

Some additional pain points around insurance payment processing include: Manual entry and a lack of automation create bottlenecks and increase the risk of human error.

Inaccurate payment posting can lead to over or underpayments, missed secondary billing opportunities, and patient dissatisfaction.

Free up billing teams to focus on strategic work instead of repetitive tasks.

Track payor performance and appeal underpayments faster.

This results in several key challenges, including: Disparate systems that don’t communicate or consolidate billing data.

Lack of actionable insights into billing patterns, payor performance, or denied claims.

Minimal transparency into provider productivity or patient-level financial trends.

Using analytics, practices can move from reactive to proactive revenue cycle management. Instead of waiting for issues to show up in the bottom line, advanced reporting tools surface trends, inefficiencies, and opportunities for improvement in real time.

BC Advantage Magazine

www.billing-coding.com

37

Additionally, the right reporting tool can show much-needed insights, such as when providers consistently undercode, which CPT codes get denied most often, where your practice is leaking revenue from aged AR, and more.

Take RXNT’s RCM and clinical analytics dashboard, for example.

These tools offer integrated, easy-to-use reporting with drill-down capabilities, giving healthcare practitioners a full picture of clinical performance and financial health, which helps improve decisionmaking and patient outcomes.

For a more in-depth look at how advanced analytics can improve your practice, check out “A Guide to RXNT’s Advanced Reporting: Clinical and RCM Analytics.”

Create More Efficient Billing and Payment Workflows With RXNT Optimizing your billing and payment workflows isn’t just about saving time—it’s about strengthening your revenue cycle, improving staff productivity, and creating a better financial foundation for your practice. Whether it’s tightening up charge capture, streamlining insurance payment posting, or using advanced reporting to guide smarter decisions, even small improvements can lead to meaningful results.

With RXNT’s fully integrated, cloud-based software, eliminating inefficiencies and taking control of your billing operations is faster and easier than ever. From mobile charge capture to advanced analytics and simplified insurance payments, RXNT is designed to meet the real-world needs of healthcare professionals.

Ready to learn more? Contact RXNT today.

Vidisha Pulaguru Srikanth is a Senior Product Manager, Practice Management at RXNT. She has been in the health tech industry for more than 5 years, helping healthcare organizations and billing companies develop efficient workflows. She’s passionate about giving healthcare professionals the tools to successfully navigate complex challenges in medical billing and revenue cycle management. www.rxnt.com

38

BC Advantage Magazine

www.billing-coding.com

BC Advantage Magazine

www.billing-coding.com

39

How to Successfully Negotiate Insurance Payor Contracts for Better Reimbursement Rates

N

avigating the complexities of health insurance contracts with providers is a critical endeavor for private practices aiming to maintain financial health and continue delivering quality patient care. As insurance companies tighten reimbursement rates, healthcare providers must take a proactive approach to negotiations.

Without an effective strategy, physicians risk revenue declines that could impact their ability to provide quality services.

Common terms and clauses to know: Fee Schedules: The list of services and their corresponding reimbursement rates.

Reimbursement Adjustments: Terms that define how and when payments can change.

Claim Denial and Appeals Process: Steps required to contest a denied claim.

Payment Timelines: Specifies how quickly payors must process payments.

This article provides a comprehensive guide to negotiating payor contracts successfully, leveraging proven strategies to secure higher reimbursement rates.

By familiarizing yourself with these terms, you can identify unfavorable clauses and negotiate better contract terms.

Understanding Health Insurance Contracts with Providers

Why Negotiation Is Essential for Profitability

What is a Payor Contract?

Insurance companies often propose fee schedules that favor their bottom line. If left unchallenged, these rates can lead to financial strain for healthcare providers.

A payor contract is a legally binding agreement between a healthcare provider and an insurance company. It outlines the terms of service, including reimbursement rates, claims processes, and payment schedules. Understanding these contracts is essential before entering negotiations to ensure fair and sustainable compensation for your services.

Negotiating payor contracts ensures: Fair reimbursement for services rendered.

Increased revenue potential.

Financial stability and sustainability for your practice.

40

BC Advantage Magazine

www.billing-coding.com

Benchmarking and Market Research Understanding what other providers in your area are being reimbursed can strengthen your negotiation position.

Conduct market research to: Compare your current rates to industry standards.

Identify payors that offer better rates for similar services.

Use data to justify your request for higher reimbursements.

Strategies for Negotiating Better Payor Contracts Establish & Articulate Your Value Demonstrating your practice’s unique value is pivotal.

Preparing for Negotiation Map Out Your Strategy A well-defined strategy is the cornerstone of successful negotiations. Start by analyzing your current contracts to identify start and end dates, ensuring ample time for discussions. Assign a primary negotiator within your practice to maintain clear communication with payors. Clearly outline your objectives—whether it’s achieving a specific percentage increase or overall improvements—to stay focused during negotiations.

Highlight: Specialties that differentiate your practice from competitors.

High patient satisfaction rates.

Data on how your care reduces unnecessary hospital visits, benefiting payors financially.

A data-driven analysis strengthens your position.

Engaging a rate negotiation expert can also help craft a compelling value proposition that showcases your strengths objectively.

Key tactics for success:

Review Your Contract Terms Thoroughly Health insurance contracts with providers often contain complex language that can impact your revenue.

Scrutinizing your agreements can help you identify areas for improvement: Are reimbursement rates aligned with market averages?

Are there unfavorable clauses that allow unilateral rate adjustments?

Are payment timelines delaying cash flow?

If any of these issues exist, they should be addressed in negotiations to protect your financial interests.

Present Competitive Data: Use benchmarks and regional comparisons to justify rate increases.

Leverage Patient Volume: If your practice sees a high volume of patients, use it as leverage to negotiate better terms.

Negotiate Multi-Year Contracts: Longer agreements offer stability and can lock in favorable rates.

Propose Alternative Payment Models: Explore value-based reimbursement arrangements that benefit both parties.

BC Advantage Magazine

www.billing-coding.com

41

Build Stronger Relationships with Payors

Handling Pushback from Payors Insurance companies may push back against rate increases.

Be prepared to: Justify requests with clear data and documentation.

Offer counter proposals that benefit both parties.

Walk away from unfavorable contracts when necessary.

Legal and Compliance Considerations Understanding contract language is critical to avoiding pitfalls.

Ensure compliance by: Reviewing agreements for hidden clauses that could impact your revenue.

Consulting with legal professionals when necessary.

Staying informed about state and federal regulations.

Post-Negotiation Best Practices Maintain Persistent Follow-Up Consistent communication is key. Identifying the right payor representative can be challenging, and they may avoid negotiations. Regular follow-ups via email or phone ensure the process moves forward. Setting reminders and tracking communication history prevents negotiations from stalling.

Track and Monitor Contract Performance After securing a new contract, ensure payors uphold their end of the agreement.

Do this through: Reviewing payments regularly for discrepancies.

Identifying patterns of underpayment or delayed payments.

Preparing for future renegotiations by monitoring contract performance.

A positive relationship with payors can lead to more favorable negotiations in the future. Maintain professional and open communication to keep negotiations constructive and mutually beneficial.

Conclusion Negotiating payor contracts is a necessary step in ensuring your practice’s financial stability. By leveraging data, articulating your value, and implementing strategic negotiation tactics, you can secure better reimbursement rates and protect your bottom line. Take a proactive approach, be persistent, and don’t settle for unfavorable terms—your practice’s long-term success depends on it.

If you need assistance with payor contract negotiations, consult with NGA Healthcare to conduct an audit of your existing contracts to identify areas for improvement.

Contact NGA Healthcare’s negotiation and credentialing experts today to help optimize your practice.

Nathaniel Arana, Principal, NGA Healthcare, has many years experience in business and in the healthcare field. Nathaniel earned a management degree from the Eller College of Management with an emphasis in operational management and organization. He helped start an out-of-network billing and consulting business from concept to profitability. Thereafter, he managed and grew a healthcare consulting business; under his management, the business dramatically increased its revenues and clients.

Nathaniel started NGA Healthcare because he found that practices were looking for consulting companies that could provide results-not just empty promises. Since then, NGA Healthcare has worked with all specialties to help grow, reorganize, and make practices more profitable. Nathaniel regularly contributes to many healthcare business magazines and companies as an expert in practice management.

A physician advocate, Nathaniel believes in working directly with his clients to achieve, and surpass, their goals. www.ngahealthcare.com

42

BC Advantage Magazine

www.billing-coding.com

BC Advantage Magazine

www.billing-coding.com

43

How Real-Time Data Analytics Is Revolutionizing Patient Care

P

atient care remains the top priority for healthcare providers. But in a swiftly evolving technological world, conventional methods for managing and enhancing care might fall short. This is where real-time data analytics can make all the difference.

Real-time data analytics is an innovative tool revolutionizing healthcare operations and reshaping perspectives on patient outcomes—and with the potential to quite literally save lives.

This article explores how real-time data analytics help healthcare now and in the future. We’ll also look at how it can help you make more informed, impactful, and personalized patient care decisions.

What Are Real-Time Data Analytics?

Real-time data analytics refers to the instant gathering, processing, and analysis of data as it is created. Traditional data analysis relies on historical, structured data and operates on a delayed timeline. In contrast, real-time analytics delivers actionable insights that healthcare providers can use immediately.

Before diving into examples of real-time data, it’s essential to describe the four main types of healthcare data analytics.

44

BC Advantage Magazine

www.billing-coding.com

They include: Descriptive: Focuses on understanding past data to identify basic trends and patterns.

Diagnostic: Explores the root causes of events.

Predictive: Uses historical and current data to forecast future outcomes.

Prescriptive: Recommends specific actions based on data analysis, optimizing outcomes.

Now that we understand the types of analytics, here are a few examples of sources for real-time healthcare data: Wearable devices like fitness trackers, cardiac bands, and smartwatches monitor health metrics such as heart rate, glucose levels, and physical activity.

EHR (electronic health record) systems that maintain up-to-date medical records for instant access and analysis.

IoT (Internet of Things) medical devices, such as remote patient monitoring (RPM) tools that track patient vitals from their homes, ensure ongoing care without hospital stays.

Imaging systems and AI-powered diagnostic tools that analyze scans, X-rays, and lab results in real-time to identify critical issues immediately.

By leveraging these data sources, healthcare providers can move from reactive to proactive care models, creating a significant shift in how care is delivered.

How Do Real-Time Data Analytics Help Healthcare Providers?

The benefits of real-time predictive data analytics in healthcare go far beyond access to faster information. Here’s how it directly impacts patient care and the provider’s decision-making process.

Improving Day-to-Day Decision-Making Utilizing artificial intelligence (AI) and machine learning (ML) in healthcare analytics is one way providers can improve day-to-day patient care. Real-time insights from this data allow healthcare professionals to act quickly in time-sensitive situations.

In an emergency room setting, AI can assist in the early detection of patients with life-threatening diseases and promptly alert providers so the patients can receive immediate attention.

For example, a wearable device may notify providers of a sudden drop in a patient’s oxygen levels, spurring immediate intervention to prevent a critical event.

Enhancing Care Coordination With Analytics Medical team members can coordinate more effectively with real-time predictive analytics and data flowing seamlessly between departments. For instance, lab results can be instantly shared with physicians, surgeons, and specialists, enabling a faster and more unified treatment plan.

A case study from Perspectives in Health Information Management reveals that one of the largest healthcare service providers in the state of Washington collected realtime data with advanced ML and AI algorithms.

Better Care Decisions for Patients Improving patient outcomes with predictive analytics in healthcare has come a long way. Access to real-time data allows for early diagnosis and targeted treatment plans tailored to each patient’s needs and circumstances. One literature review, NIH’s ”The Use of Big Data in Personalized Healthcare to Reduce Inventory Waste and Optimize Patient Treatment,” states that this personalized treatment may include adjusting medication dosages and diet, recommending specific therapies, or considering differential diagnoses. For example, oncologists can use real-time predictive analytics to identify effective chemotherapy protocols for specific cancer patients, improving treatment outcomes while reducing adverse effects.

Risk Management Through Healthcare Data Analysis For patients with chronic or high-risk conditions, realtime healthcare data monitoring reduces the likelihood of hospital readmissions or adverse events. For example, the aforementioned literature review states that IoT systems use sensor data, which helps with the early detection of emergencies. These anomalies in vital signs can trigger automated alerts to family members, potentially saving lives, especially in elderly populations. By analyzing realtime datasets, providers can also identify risk factors and predict which patients are most likely to develop certain conditions. This allows for earlier interventions that can prevent the onset of chronic diseases like diabetes.

The Future of Real-Time Data Analytics in Healthcare

They used this data to: Coordinate patient care and resources across the entire health system.

Real-time data analytics is already making strides in healthcare, but what’s ahead is equally exciting.

Streamline care delivery.

Here are key trends to watch:

Allow care teams to solve problems proactively.

By harnessing this technology, the system coordinated care more efficiently and improved safety for all its patients. For example, “lost cases” were reduced by 20% in the year’s first six months.

Through additional admissions and the prevention of lost cases alone, the program created a contribution margin equal to 74% of its labor cost in the first year of operations.

AI-Powered Analytics: Artificial intelligence is expected to enhance real-time predictive data analytics by offering even more precise prognoses and identifying patterns the human eye might miss.

Real-world example: A report by HTN reveals that a new AI software is twice as accurate as physicians’ ability to examine the brain scans of stroke patients. The software could also estimate the biological age of the lesions, helping to determine whether the stroke may be reversible.

BC Advantage Magazine

www.billing-coding.com

45

Wearables for a Healthier World: The growth of wearable devices will bring even more opportunities for personalized medicine through data analytics.

Real-world example: Engineers developed a stretchy electronic skin patch worn on the neck to track blood pressure and heart rate while measuring the wearer’s levels of glucose, lactate, alcohol, or caffeine.

It’s the first wearable device that monitors cardiovascular signals and multiple biochemical levels in the human body at the same time.

Population Health Management and Analytics: By aggregating data from diverse sources, real-time analytics will become instrumental in managing population health. Providers will be able to address public health concerns more effectively by identifying trends and patterns within at-risk communities.

Real-world example: Advanced home-based AI-powered remote patient-monitoring applications for users with multiple chronic health conditions are transforming population health management by gathering data elements in ways that previously proved impossible.

Piali De, CEO of Senscio Systems, tells Modern Healthcare, “Discovering correlations [within AI patient monitoring data] is the essence of population health management because it’s impossible to know what’s working for the most complex populations without the use of AI.” How can healthcare providers drive adoption and innovation in data analytics?

Here’s how: Educate and upskill: Stay informed by attending webinars and conferences, listening to podcasts, enrolling in data analytics courses, and keeping up with industry white papers and publications.

Partner with tech providers: Collaborate with companies offering analytics platforms or wearable devices to explore innovative solutions tailored to your practice.

Advocate for integration: Push for better integrating real-time analytics tools with existing EHR systems to improve data accessibility and usability.

How Healthcare Professionals Can Get Started with Real-Time Data Analytics Want to dive into this new arena but unsure where to begin?

46

BC Advantage Magazine

www.billing-coding.com

Here are practical steps to help you integrate real-time analytics into your practice: Invest in Scalable Technology: Start small with tools and software that offer immediate ROI. For instance, wearable devices for high-risk patients with chronic health issues or analytics platforms that plug directly into your EHR system.

Start with a Single Use Case: Focus on solving one problem at a time, such as reducing readmissions for a specific condition or improving appointment scheduling through predictive analytics.

Train Your Medical Team: Equip your staff with the knowledge they need to leverage analytics effectively.

Provide training on interpreting real-time dashboards or using IoT devices to improve patient outcomes.

Leverage Pilot Programs: Test analytics solutions with a smaller group of patients or one department before scaling them to the entire practice.

Assess Your Current Systems: Evaluate your existing EHR, patient monitoring tools, and other technologies. Identify areas where real-time data could make the biggest impact (e.g., chronic care management, diagnostic imaging).

Also, make sure your practice software, which houses essential data and analytics, easily integrates with your EHR. For example, CollaborateMD is practice management software that can be seamlessly integrated with EHRs to improve clinical workflows and patient care.

This solution uses advanced real-time analytics to enhance patient data management, billing processes, effective care coordination, and communication.

By leveraging this data, providers can refine treatment strategies, predict patient trends, intervene early and prevent adverse outcomes, and improve patient engagement and boost revenue.

Conclusion Real-time data analytics has the potential to revolutionize how healthcare providers operate. Using tools that aggregate and analyze data instantaneously allows providers to make faster, more informed decisions while offering personalized, seamless patient care.

Are you ready to begin your data analytics journey? Contact CollaborateMD today to see how integrated practice management software can support your practice goals and improve patient care.

Kelsey Zaporowski, CollaborateMD. CollaborateMD.com

I

THE CRITICAL IMPORTANCE OF CYBERSECURITY FOR MEDICAL OFFICE MANAGERS

n today’s digital age, cybersecurity is no longer an optional consideration for medical office managers and physician owners; it’s a necessity. With healthcare practices increasingly relying on electronic health records (EHRs), telehealth platforms, and interconnected medical devices, the risk of cyberattacks has skyrocketed. For small and solo physician practices, the stakes are especially high; a single breach can compromise patient trust, disrupt operations, and lead to devastating financial and legal consequences. Fortunately, resources like professional certifications—such as the Health Information Technology Certified Manager for Physician Practice (HITCM-PP)—and free training from organizations like the Professional Association of Health Care Office Management (PAHCOM) can empower medical office managers to tackle this massive and often overwhelming topic with confidence.

48

BC Advantage Magazine

www.billing-coding.com

Why Cybersecurity Matters in Medical Practices Medical offices, regardless of size, are prime targets for cybercriminals. Patient data—rich with sensitive information like Social Security numbers, medical histories, and insurance details—is a goldmine for hackers. Ransomware attacks, phishing scams, and data breaches have surged in recent years, with healthcare organizations facing some of the highest costs per breach of any industry. For small practices, the impact is magnified; they often lack the robust IT departments of larger institutions, making them more vulnerable to exploitation.

A breach doesn’t just threaten patient privacy; it can halt practice operations, erode patient confidence, and trigger steep penalties under regulations like the Health Insurance Portability and Accountability Act (HIPAA). For physician owners, the responsibility falls heavily on their shoulders, as they are ultimately accountable for safeguarding their practice. Medical office managers, however, play a pivotal role as the frontline defenders, overseeing the systems, vendors, and staff that keep the practice running. Without a solid grasp of cybersecurity, both managers and owners risk leaving their practice exposed.

Breaking Down Cybersecurity Into Manageable Segments Cybersecurity can feel like an insurmountable challenge, especially for busy medical professionals juggling patient

Free Resources From PAHCOM: No Excuses Still feeling overwhelmed? PAHCOM has your back with free information and training that make cybersecurity accessible to every practice. care and administrative duties. The good news? It doesn’t have to be. By breaking it down into segments tailored to the unique needs of medical practices, the topic becomes far less daunting.

Here’s how it applies directly to your practice: 1

2

3

4

5

Protecting Patient Data: EHRs and billing systems are the backbone of modern practices, but they’re also prime targets. Understanding how to secure these systems—through encryption, access controls, and regular updates—is critical.

Vendor Management: Many practices rely on thirdparty tech vendors for EHRs, billing software, or telehealth platforms. Managers need to know how to evaluate vendor security practices and negotiate contracts that prioritize data protection.

Staff Training: Human error is a leading cause of breaches—think phishing emails or misplaced laptops.

Educating staff on basic “digital hygiene” can prevent costly mistakes.

Regulatory Compliance: HIPAA and other laws set strict standards for data security. Non-compliance can lead to fines, but more importantly, it puts patients at risk.

Incident Response: No system is foolproof. Having a plan to detect, contain, and recover from a cyberattack minimizes damage and restores operations quickly.

These segments aren’t just theoretical; they’re practical, actionable areas where medical office managers can make a real difference. But where do you start? That’s where professional certification comes in.

Through their partnership with the U.S. Department of Health and Human Services (HHS) under the 405(d) Program, PAHCOM offers resources like: Cyber-Awareness Information: Simple, actionable tips to protect your practice.

Threat Identification Posters: Visual guides to recognize and respond to common cyber threats.

Webinars and Guides: On-demand training to build your skills at your own pace.

These tools are designed with small practices in mind, stripping away jargon and focusing on what matters most: keeping your patients and practice safe.

Available at no cost, they eliminate any excuse for not taking action. Visit PAHCOM’s 405(d) No Excuses page (https://my.pahcom.com/405d-noexcuses) to dive in and start fortifying your defenses today.

with a strong emphasis on cybersecurity. It’s not just a badge; it’s a roadmap to understanding and managing the digital risks your practice faces.

The HITCM-PP breaks down the complexities of health information technology into four key domains, including: HIT Systems Environment: Grasping the fundamentals of EHRs, usability, and functionality.

The Power of the HITCM-PP Certification

Laws and Regulations: Navigating HIPAA, patient safety standards, and privacy rules.

For medical office managers and physician owners looking to master cybersecurity, the Health Information Technology Certified Manager for Physician Practice (HITCM-PP) certification, offered by PAHCOM, is a game-changer. This nationally recognized credential validates expertise in the technology-related aspects of running a medical practice,

Technology Trends: Keeping up with innovations like Promoting Interoperability and MACRA while staying secure.

Cybersecurity Basics: Identifying threats and implementing safeguards tailored to small practices.

BC Advantage Magazine

www.billing-coding.com

49

Earning the HITCM-PP demonstrates to physicians, staff, and patients that you’re equipped to handle the technological challenges of modern healthcare. It’s especially valuable for small practices, where managers often wear multiple hats and can’t rely on a dedicated IT team. Plus, the certification process itself—complete with study guides and practice exams—builds practical knowledge you can apply immediately. For physician owners, having a HITCMPP-certified manager on staff offers peace of mind and a competitive edge in an industry where trust and compliance are paramount.

Conclusion: Cybersecurity isn’t just an IT issue; it’s a practice management issue. For medical office managers and physician owners, ignoring it isn’t an option; the risks are too high. By leveraging professional certifications like the HITCM-PP (https://my.pahcom.com/hit), you gain the - If you are out of state temporarily (e.g., vacation), then the Medicare rules do not apply. You should still investigate the medical-legal aspect of state licensure in that circumstance.

Here are some examples using a hypothetical practice located in Massachusetts: • •

•

•

•

You work and live in Massachusetts; you may read and create final reports from home.

You work in Massachusetts but live in New Hampshire; you may create final reports from home if you have a New Hampshire license and notify the billing team of the reading address. You may create preliminary reports from home if the final is signed off from the hospital.

You live and work in California reading exams done in Massachusetts; you must have a license in both California and Massachusetts and notify the billing team of your reading address.

You work and live in Massachusetts but are on vacation in Cape Cod, MA; you may create final reports. There is no need to notify billing.

You work and live in Massachusetts but are on vacation in Florida; you may create final reports but check on the legal aspect of licensure. There is no need to notify billing.

Some practice systems might automatically capture reading location, but in the end, it is the physician’s responsibility to notify the practice about their work location. Making them aware of these guidelines, especially as they relate to medical licensure, 50

BC Advantage Magazine

www.billing-coding.com

Payment Locality Reporting for Radiology Professional Services

knowledge and credibility to protect your practice from digital Pair that PAHCOM’s training, and will helpthreats. to ensure that thewith practice is in fullfree compliance. you’ve got a powerful toolkit to break down this massive Conclusion topic into manageable, practice-specific steps.

In an eraavailability where cyber threats evolveand daily, ahead The easy of remote reading the staying post-pandemic means stayingwork informed.

Investthe in your tap into free shift to off-site has renewed need skills, for practices to be resources, take control your practice’s future.

Your aware of theand Medicare rules forofreporting the place of service in order to be compliant.

After-hours reading by radiologists in patients—and your peace of mind—depend on it. distant locations will produce a reimbursement rate different than the one in effect at the imaging center or hospital. In some cases, this can be used strategically to move interpretations to Karen with Blanchette, MBA, is the Executive a location higher reimbursement rates. The Director first step of is to develop a system that allows the billing team to know the PAHCOM. The PAHCOM collaborative network enables location the reading so theyphysician can be sure to applyto the solo of providers andservices, small group practices rules properly. access focused information vital to managing their healthcare businesses effectively. Contact Karen at Table 1: See below https://my.pahcom.com/contact-karen.

Trained and professionally certified managers make a

Sandy Coffta is Vice President of Client Services with Healthcare difference. Learn more about the CMM and HITCM-PP Administrative Partners. In this role, Sandy oversees the team at https://my.pahcom.com/certifications. responsible for achieving and maintaining the company’s consistently high retention and referral rates. Ms. Coffta has over 17 years of experience in client relationship management, including reimbursement analysis, workflow optimization, and compliance education. She specializes in business intelligence and reporting development, is a subject matter expert in radiology practice billing, and has deep expertise in resolving payor disputes and contract issues. www.hapusa.com

Everyone who logs into any device at the practice needs to be cyber-aware!

The IT Guy, if you have one, might be the person you direct questions to. But every user on a network must be aware of basic threats and know what to do when they see one. The “weakest link” concept applies and each user is a link.

www.pahcom.com

YOUR FULL SERVICE RADIOLOGY RCM PROVIDER www.hapusa.com info@hapusa.com BC Advantage Magazine

www.billing-coding.com

51

BC

Magazines | CEUs | Webinars www.billing-coding.com

ADVANTAGE

New subscriptions www.billing-coding.com/subscribe Renewals (Keep your rate for life*) www.billing-coding.com/renewals

www.billing-coding.com 52

BC Advantage Magazine

www.billing-coding.com