The Best Medicine for Healthcare is Better Medical Billing
Well designed medical billing processes will play a critical role in driving down healthcare costs. This article discusses this link and the role medical billing services can play in helping make healthcare more affordable.
One of the root causes of today’s rising healthcare cost has been touched on but not properly explored in the round of debates about how to fix healthcare in the United States. The issue? The methods being used by insurance companies to extract money from providers through a ludicrously inefficient claim adjudication process.
The tactics used by payers to save money (and drive up the cost for medical practices to operate a medical billing process) include: Underpaying over 10% of medical claims, “losing” submitted claims on a regular basis, and constantly changing the rules by which they decide if claims are actually payable. If the provider’s medical billing process is not technology savvy, well designed and properly staffed then over 20% of the practice’s revenue can easily be lost to these tactics.
There is a strong economic motivation for payers to maintain the current inefficient billing process. They can increase their profits sharply since more than fifty percent of the claims they misplace or accidently underpay are never noticed by medical providers.
Nothing is free, so payers do incur a price on their end because of the current process. It cost about $25 when a payer that has spotted an underpaid or missing claim gets a insurance representative on the phone. This has lead payers to get quite clever and grade each medical provider. The grade is based upon how well the provider spots issues and calls the payer (thus generating costs for the payers). If the provider catches the payers “mistake” each time they will be rated an A. If they never catch the payer’s errors they will receive a F. Interestingly, the payers that are rated an F seem to have many more lost and underpaid claims than those rated an A.
So, how do all of these facts tie lead to the conclusion that better medical billing processes can lowering the cost of healthcare? If each and every underpaid or lost claim is pursued (which is what a well-designed medical billing process should do) then eventually payers will lose all economic incentive to play games and make the medical billing process complicated and expensive.
If the medical practices and medical billing services dig in and fight for the last dollar on every claim they will quickly force the insurance payers to adjust their internal processes. With each claim paying in full and their staff inundated with billing specialist asking why a claim was lost or underpaid, the payers will see rapidly shrinking profits that will force them to acknowledge that the costs of the games they play are no longer justified by the savings form unpaid claims.
There is lots of talk about the dream system where claim adjudication happens in real time and physicians immediately receive their reimbursements. Such a system will never happen until the economic incentive payers have to maintain a difficult, complicated and veiled system are removed. This is what well designed and executed medical billing processes can do by doggedly pursuing each claim.
Copyright 2008 by Carl Mays II
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