decisionhealth Newsletters, Part B News - 2021 Issue 6 (June)
Low claims clearance? Before blaming billers and coders, check chain of custody
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Article Overview
This article discusses how medical practices can assess billing and coding performance more accurately by tracing where claim problems originate across the revenue cycle. It focuses on denial analysis, claim adjustment and remark codes, payer communication, workflow bottlenecks, documentation issues, and staff education. The piece is aimed at practice managers, billers, coders, and others responsible for claims processing and reimbursement oversight.
Why This Topic Matters
Using denial rates alone can misattribute errors and obscure whether problems stem from documentation, eligibility, payer changes, workflow delays, or other parts of the claim lifecycle. Understanding the broader chain of custody helps practices target training and process improvements more effectively.
Article Sections
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Assessing billing and coding performance
Introduces why denial rates and similar metrics may be incomplete measures of staff performance. Discusses the need to identify other contributors across the claims process.
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Check CARCs and RARCs
Explains the role of payer-returned adjustment and remark codes in identifying where claim problems may originate. Describes how claims review can help separate worker performance issues from other causes.
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4 places things go wrong
Reviews several common areas in the revenue cycle where problems can occur, including eligibility verification, payer rule changes, billing delays, and regulatory or workflow disruptions.
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Train for success
Focuses on education and feedback after problem areas are identified. Covers communication strategies, peer review, and the importance of documentation quality for billing outcomes.
What You Will Learn
- How denial metrics can be supplemented with broader performance review approaches
- How payer response information can be used to locate claim processing issues
- Common operational points in the revenue cycle where claims can break down
- Why documentation and staff education affect billing outcomes
Who Should Read This
- Medical practice managers
- Billers
- Coders
- Revenue cycle staff
- Physician office administrators
Codes Discussed
Modifiers Discussed
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