The pain management process helps people to move without any kind of difficulty. It has been observed that around one in four US adults have chronic pain which lasts for more than three months. Moreover, around 36% of patients having more than 65 years of age have chronic pain and there’s a huge economic impact of this. Chronic pain costs around $565 to $635 billion yearly, which costs more than diabetes, heart disease or any kind of cancer.
Due to this growing crisis, the demand for pain management billing is also rising in a large manner. The claim denials can delay payments, reduce cash flow, and drain the time for healthcare staff. Hence, denials affect spinal procedures, injections, and drug testing very often. Always remember that a denial-proof system is important to ensure stability for the clinics and continued patient care. However, as the healthcare staff stay busy with administrative hassles, that’s why it can be a feasible option to outsource pain management billing companies in that matter.
Why Denials Happen in Pain Management Billing?
Insurers deny pain management claims for several reasons, and the good news is that most of them can be easily fixed. Missing the prior authorization procedure can be one of the biggest causes as many spinal procedures and injections need approval before treatment and ignoring this step may lead to denials. The missing or outdated modifiers can cause several problems as they explain why all the services are billed separately or together. Moreover, insufficient documentation procedures can be one of the major reasons for claim denials as insurers want to know if the provided services were supported by exam notes or not.
An inefficient chronic care management process welcomes all the unwanted denials when clinics forget to record time or create a care plan for all patients having multiple conditions. The unbundling mistakes also lead to claim denials when all the services are billed separately or split incorrectly. Hopefully, you can take several steps to avoid claim denials and ensuring efficient billing process using the strategies described below.
Latest Denial Management Strategies
The strategies range from managing prior authorization to leveraging efficient processes to appeal denials. Let's describe those strategies one by one:
Managing Effectively Prior Authorization
Prior authorization is a common area causing frequent denials, and pain management billing is not an exception to it. You may need PA approvals for pain relief injections like facet joint, epidural steroid, sacroiliac joint injection, and nerve blocks. The advanced spinal procedures, high-cost medications, and several drug testing panels need timely approval. It is essential to make sure PAs get approved on time before you send any pain management treatments for all the patients. Document the decision of payers and attach MRI reports or therapy notes. If you want to improve your claim approval rate, always use clear language and provide evidence like EMG results, imaging, and note failed care with dates. However, if the claim gets denied, appeal with proper patient records to make sure no issue occurs. So, always avoid starting treatment before the PA approval process, relying on the verbal confirmations and missing PA dates, which can lead to denials. The outsourced pain management billing companies are experts in this process.
Making Sure to Use the Right Modifiers
Modifiers are important in pain management billing, but they work with the right documentation procedure. Modifier 25 is applied when a separate and significant E/M service on the same day is used, and also you need to show why it was not routine care. Moreover, modifier 59 is used when about two procedures are bundled together as separate services, though many payers prefer XP, XS, or XU modifiers for specific details. In addition to that, check payer specific rules as some payers accept modifier 59 while others push for the X modifiers. So, always train all the administrative staff members to make sure you use the right modifiers and have a cheat of payer-specific modifiers in the existing EHR system.
Carefully Understanding Payer Rules
You may have realized that payer policies can vary, hence you may develop several payer-specific rules to make sure no issue occurs. Moreover, carefully handle the commercial payers as they have stricter bundling needs and PA requirements. However, Medicare follows all the national rules but relies on the Local Coverage Determinations which create documentation for medical necessities to make sure no claim denial occurs. Some state-specific plans need stricter limitations on drug testing. It is also important to maintain a clear payer-specific note in the clinic’s EHR system and maintain a quick library of references for all the PA and LCDs.
Streamlining the Best Practices
Always speed up the payments and prevent denials using correct coding. The team needs to align the correct CPT code with the right ICD-10 code to make sure no claim denial occurs. Always remember that accurate coding paired with strong documentation process is important to avoid claim denials. Always send supporting notes like PA details, and imaging which are highly beneficial to streamline the claim submission process. So, it is important to maintain these best practices to make sure no issue occurs.
How Does the Outsourced Pain Management Billing Companies Perform?
The outsourced companies can reduce your operational costs by 80% and work with 10% buffer resources to make sure no issue occurs. Apart from that, they also provide dedicated account managers at no extra cost and have no restrictive clause or binding contract. Apart from that, these outsourced services also provide customized reports and the best infrastructure setup according to the client’s needs. They also tackle several specialties like DME, gastroenterology, infusion, cardiology, and many more. These outsourced companies have less than two days of turnaround time to make sure no issue occurs. They provide dedicated employees having US phone numbers and are 100% HIPAA compliant. So, if you want to streamline your billing process, it can be a feasible option to outsource pain management billing companies in that matter. Hence, take the step today and see the difference they can make to your clinic.
