Beginning in June of 2011, the Centers for Medicare and Medicaid Services (CMS) started streaming all fee-for-service (FFS) claims through predictive modeling protocol. The technology designed to profile medical providers, billing patterns and networks enables CMS to flag and investigate potentially fraudulent claims activity. Utilizing advanced technology and traditional investigative strategies together to identify, or prevent, improper billing allowed CMS to recover a staggering $19.2 billion in a five year span, according to the agency’s June 25, 2014 press release.
While innocuous billing does not prevent payment, it delays reimbursement to enable a thorough review and transaction data funnels back into the predictive modeling system, refining the fraud detection system. CMS Administrator Marilyn Tavenner reports the Fraud Prevention System clear demonstrates “investing in cutting-edge technology pays off for taxpayers and Medicare beneficiaries.”
Leveraging Analytics in Billing and Coding Policies
Predictive analytics is helping CMS gain a better understanding of billing practices throughout the medical community. Physicians, hospital administrators and other ancillary service providers can exploit data to improve financial performance and manage risk scores to reduce the number of red flags that trigger claim investigation, which delay reimbursements.
An ideal predictive model allows practice managers to capture a clear snapshot that anticipates monthly cash flow and helps financial leaders identify key payers and patient groups. Responsive solutions not only uncover negative trends, but also provide remedial options for decision-makers to consider. For example, health information technology enables financial leaders to aggregate, assess, and convert data into real-time information via simple and sophisticated search parameters to quickly identify payer reimbursement levels. If the system detects a payer with lower than expected performance, predictive analytics programs provide valuable strategic insight that empowers the practice or service provider to develop an appropriate corrective action plan to overcome the deficiencies.
Weaving Analytics into the Revenue Cycle
In the years leading up to wide-spread EHR adoptions and transitioning to ICD-10, The American Health Information Management Association (AHIMA) identified five key areas of focus to enable a “re-engineering” of the coding workflow. The convergence of advanced technology and leadership oversight supports a healthier revenue cycle from end-to-end.
The five steps recommended by AHIMA include:
- Assessing and mapping the coding process
- Outlining the future: Identifying key personnel, payers, patients and stations within the clinic or practice
- Recognizing gaps and implementing remedial solutions
- Defining realistic expectations and establishing performance timelines
- Implement coding process policies
Utilizing analytics helps practice managers design an efficient billing and coding protocol in the office that enables better communication with payers, third-party billers, patients and outside service providers. Health information technology enhances each of the five steps recommended by AHIMA.
While CMS leverages predictive analytics to save money by eliminating and preventing fraudulent billing practices, healthcare decision makers can exploit data to improve payer performance, manage the revenue cycle and streamline internal work flow patterns. Weaving analytics into a billing and coding protocol promises to help healthcare organizations enhance patient relationships, improve outcomes and improve financial standing. You have already invested heavily in technology and training, capitalizing on inherent system capabilities is a first step toward improving your return on investment.
We offer consulting, implementation and training advice and account management and performance audits to help position your medical organization for success. If your practice is facing challenges with sluggish reimbursement rates, or is concerned about improving your CMS risk score, M-Scribe Technologies, LLC can help. Our team of professional billing and coding experts is recognized as a national leader in the medical billing and coding industry. For a free practice review email firstname.lastname@example.org or call 888-727-4234.