Code Red: Rescue Your Healthcare Revenues

By Darren J. Hobbs and James S. Lacy, JD

As healthcare costs and insurance premiums rise at a pace that surpasses inflation, payers have responded by creating complex billing and coding rules to defend against paying ‘too much’. More than 10 years ago, CMS implemented the National CCI (Correct Coding Initiative) in an attempt to combat fraud and ensure that reimbursements were correct and paid according to the medical services actually rendered. As part of Social Security reform, Congress also mandated that Medicare only reimburse for procedures deemed as “reasonable and necessary”, forcing providers to navigate through a forest of medical necessity rules and a medical coding maze just to get paid for their services.

Medical necessity coding and CCI issues have been historically restricted to Medicare claims. However, the provisions of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA or Medicare Part D) require eligible enrollees to select coverage by private insurance and HMOs in order to take advantage of the prescription drug benefit. CMS mandates that private Medicare plans (Medicare Advantage Plans) apply CMS edits and criteria in the adjudication of payment of claims. Medicare Advantage plans have grown both in the number of plans and the number of enrollees.

The combined impact of confusing coding rules, and the number of plans impacted by these rules, have increased the difficulty and cost of submitting clean claims. This results in the need to dedicate additional resources to understand and maintain coding rules, resubmit denied claims, and accommodate workflow disturbances.

Access the full guest column to learn ways that modern technology tools can help providers lessen the impact of these challenges.