For the past few years, Medicare has been testing out new ways to bundle claims. The goal of this bundled claim switch is to improve care and reduce costs. A few apparent benefits in the bundled claims model have already been tested. One is simplifying the billing process by instituting a single price for all episodes of care, regardless of the services provided. This incentivizes improved quality of care and theoretically reduces the amount of required paperwork.

Bundled claims could be concerning for healthcare providers. This model moves the risk of cost from payers to providers. If the care provided is more expensive than the typical episode of care payment, providers are accountable for the difference. The difference between gaining and losing revenue is all in the details. 

Take a look at our four tips for avoiding disallowed charges and maximizing your success as a healthcare provider.

1. Understand the Bundling Claims Process

Naturally, the first step to avoiding disallowed claims is organizing and submitting everything correctly the first time. A general structure for what your process should look like is as follows:

    • Charge Master Review of additions/deletions is necessary to ensure your facility appropriately charges for services rendered and payable. Appropriate financial reserves may be necessary when services billed are known not to be payable.
    • Bundled services may/may not be a coding edit. Supplies are often considered floor stock and included in room and board charges; reusable equipment is not payable given said equipment can be used on multiple patients. Many health plans perform forensic reviews to determine if bundled/disallowed charges are included on a given claim, specifically when over a given threshold, resulting in a payment reduction for line-item services.
    • Contract language will define the outlier threshold when the majority of claims are paid at DRG. If the claim’s dollar amount is more significant than the outlier, then claims are often paid at a percent of charges. Health plans will review line item charges and remove them from the claim resulting in a dollar amount lower than the contracted outlier and, if so, pay the claim at DRG.
    • Prior to submitting a claim, determine if line item charges are bundled and therefore not a payable service. Doing so allows you to remove said charge from the claim or incorporate appropriate financial reserves if the service is billed.
    • Pre claim submission reviews of line item charges billed will educate clinicians, coders, and healthcare workers and avoid costly denials and lack of appropriate payment.

If your process matches the description above and is executed appropriately, disallowed charges can be avoided upfront.

2. Continually Check Eligibility

One of the best ways to prevent disallowed charges is to make sure your clinical staff is constantly ensuring that their payer covers an episode of care. Eligibility and registration errors account for almost 24% of all claim denials, and an additional 12.4% are due to incomplete or missing authorizations. By educating your staff to stay vigilant about eligibility, you can reduce denials by over one-third, saving your company time, effort, and a substantial value to your bottom line. 

3. Invest in Automation Technology

A common cause of billing errors is understaffing and improper training of medical billers. Since bundled claims are relatively new, many billers don’t have a lot of experience with them, and in turn, it becomes more challenging to improve provider’s Clean Claim Rate (CCR). One of the most straightforward ways to combat these errors is through automation technology such as TruCode Integration with Apello. This software helps standardize and expedite workflow while ensuring that critical information is passed between provider and payer without delay.

4. Conduct Pre-Bill Reviews

When reviews are proactive, denials occur less often. That is why you should always perform audits before the bill is dropped; this will ensure clinical documentation supports the billed services and that the episodes were medical necessity. Within the 48-hour window of the patient’s release and the bill drop, the outsourced services team can step in for documentation checks and ultimately clean up any mistakes, such as coding errors or insufficient documentation. 

Reducing the number of disallowed charges from bundled payments can be tricky, especially when physicians, billers, and other clinical staff are busy worrying about traditional payment models too. Even so, by following the tips we’ve outlined above, you will be well-positioned to continue providing high-quality medical care without having to suffer underpayments in an increasingly value-based care reimbursement system.