How to Increase ER Profitability with a Medical Revenue Service

While Emergency Medicine providers selflessly continue caring for their patients, many emergency departments still endure the detrimental financial impact of COVID-19. In a 2020 study of emergency departments, researchers found that ED visits decreased drastically, up to 63.5% in some states.

 

Even though it is evident that ED patient volumes are slowly bouncing back, it is getting harder and harder to maintain profitability or even solvency of the independent ED groups.

If your revenues are not being handled efficiently, a considerable amount of the hard-earned revenue may slip through the cracks.

There are several ways an expert revenue cycle management service can help providers optimize their financial outcomes. First, let’s examine some of the reasons revenue could be lost.

Why Do We Lose Revenue in the ED?

The main reason for recent revenue loss in emergency departments is a decrease in patient visits. In a study at one major hospital, emergency department visits decreased by 30.4% in April of 2020 compared to April 2019.

Each hospital sector has seen a different effect from the pandemic – from an influx of intensive care patients to the complete ban on performing elective surgeries in many hospitals.

For the emergency departments, the primary trend has been the decline in visits. Fear of contracting the virus and measures implemented by the healthcare facilities to prevent its spread lead to several profound consequences:

  1. Patients not seeking emergency care, even for life-threatening conditions
  2. Patients avoiding healthcare facilities in general, but especially hospitals
  3. Widespread adoption of telemedicine

The decline in the ED visits has caused a significant loss of revenue, and consequently, heightened the need to re-focus on improving collections practices.

How to Increase ER Profitability

Focus on Excellence in Customer Service

Patient satisfaction is as crucial as collections when it comes to a successful ER. Many patients do have a choice as to which ED they visit, even in an emergency. If your reputation isn’t excellent, you may lose out on potential revenue. And while it is a given that excellent customer service is vital, recent studies consistently demonstrate that the hospitals with the highest profit margins are those with the highest patient satisfaction. Providing an exceptional patient experience can increase profitability by up to 50%!

Review Vendor Contracts to Reduce Costs

  • Require that vendors perform self-audits to save time and costs
  • Revisit payment schedules to improve both short-term and long-term cash flow
  • Ensure that your legal counsel reviews all contracts to eliminate hidden costs

Reduce Unnecessary Testing in Your Emergency Department

In a study from choosingwisely.org, nearly half of doctors say patients request an unnecessary test at least once per week. Thirty percent say this actually happens several times a week. In another study published in the American Journal of Clinical Pathology, $6 billion per year in the US is spent on procedures and testing that aren’t medically necessary.

This practice increases healthcare costs in general, leading to inefficiencies in clinical care and reduced profitability. 

Understand Your ED’s Data

Emergency medicine providers can gain valuable insights from analyzing key performance indicators to monitor the group’s financial health and identify improvement areas.
For example, you may find that your patients spend too much time in registration. Determining the cause of this slow-down can help streamline patient intake processes.

Related: How to Effectively Reduce Your ER’s Wait Times

Utilize a Dedicated Revenue Cycle Management Service

During the COVID-19 public health emergency, it has become much more difficult to collect revenue. Unemployment rates in the United States skyrocketed to nearly 16% in 2020, and while they have improved greatly,  the numbers are still hovering around 6% in 2021, which is over 2% higher than pre-pandemic levels.

This translates to 9.7 million unemployed individuals, who may have become uninsured and don’t have the means to cover emergency medical expenses.

Utilizing DuvaSawko’s expert Revenue Cycle Management Services will ensure that your ED will remain stable and profitable, even in these otherwise uncertain times. DuvaSawko’s billing and coding solutions have been shown to increase ED revenues by up to 30% each year.

Founded and operated by ED physicians over 20 years ago, DuvaSawko is committed to increasing efficiencies, mitigating compliance risk, and helping you grow. We provide:

  • Expert analysis of your ED’s performance with a dedicated account manager that helps assess the most meaningful KPIs, accelerating collections and ensuring accurate records
  • Guidance in making business decisions that impact revenue
  • Reports that are tailored to your ED’s specific needs
  • A business growth partner to help you view your practice from every direction and become more profitable.
  • A dedicated team to help you succeed.
  • Faster and more accurate reimbursements
  • An up-to-date, proprietary software for billing, coding, and data reporting. We quickly adapt to all regulatory updates and changes in the healthcare industry.
  • The ability to free up doctors and nurses so that they don’t need to spend precious time on billing matters

A partnership with DuvaSawko will allow you to utilize your ED’s resources more effectively, will help you significantly increase economic efficiency, and, most importantly, will allow your providers to focus on what they do best – taking care of their patients.

Click here to schedule a complimentary practice analysis today.

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How To Prepare For Challenges Facing Emergency Departments in 2021

While the state of EM is always unpredictable, COVID-19 has made it even harder to prepare for challenges facing emergency departments.

While the state of emergency medicine is always unpredictable, COVID-19 has made it even harder to determine where we may be in a day, a week, a month, or a year.

We don’t always know what to expect, but we can prepare our EDs for challenges we may face in the coming year – both while COVID-19 is still in existence and through the hopeful slowdown of the pandemic.

Here, we will discuss the challenges we may face in the coming year and how to prepare for them to ensure our EDs can continue to thrive.

Post-COVID Year One: What is a Challenge Facing Emergency Medicine?

COVID-19 is not over, and we’re still experiencing spikes and lulls in our cases from behind ER doors. 

We are hopeful for a pandemic slowdown in 2021, but we are still reaping the prior year’s consequences and will continue to encounter hurdles throughout the year.

Difficulty in Patient Bill Collection

During this challenging pandemic period, ED revenue is becoming more difficult to collect

Just before March of 2020, unemployment rates in the United States hovered around 3.5%. By April and May, they skyrocketed to nearly 15%. While the rates have steadily decreased since then as businesses have adjusted to a new standard, they remain above what they were, at almost 7%.

With these increased unemployment rates and no immediate return to normalcy in direct sight, patients are more likely to be self-pay and unable to afford their mandatory care. 

Not only is revenue collection a challenge, but patients are left to decide whether the financial constraint is more or less dire than their ailments potential diagnoses. This choice, along with other factors, may be another reason for decreased ER visits.

The Continuation of Decreased Emergency Room Visits

We continue to see fewer visits from patients with specific concerns as fear resumes its role in deciding whether to visit the ER. In 2020, DuvaSawko saw a 45-50% drop in emergency patient visits when COVID-19 became prevalent at the start of the year.

According to a 24-emergency-department study, patient volume during the pandemic decreased by 41.5% and 63.5% in Colorado and New York, respectively. Across all healthcare systems, the ED visits decreased by over 40%.

On top of reduced or late visits for potentially life-threatening symptoms, once these patients’ ailments worsen, the visit that may have once been a minor treatment intensifies into something more severe. Once a case is more urgent and life-threatening, the ED staff must pool resources to treat the patient, taking away from the in-and-out flow that once allowed quicker turnaround.

Fear is a primary factor of these reduced visits. Fear of contracting the virus from a visit to a place where there is no doubt the virus exists; fear of long wait times due to preoccupied staff; or fear of not having the funds to pay for treatment. 

There are steps we can take as a successful ED to ensure we can continue to help our patients in the most efficient way possible and collect the revenue required to flourish.

How To Prepare for Challenges of 2021

If there is one thing we have learned in this past year of ups and downs, it’s the importance of metrics and having a full understanding of the numbers that matter. 

Whether it’s statistics on how much each patient costs the ED, the amount of time it takes to process a patient, or the amount of time they have to wait to be seen – knowing and understanding these statistics is just one group of numbers you should be studying.

Keep Abreast of Trends In Your Geographic Region

Watching the numbers is vital for internal organizational processes and external factors that can affect your ED as well. It’s essential to know and understand what is going on around your area at all times, especially when any significant changes can and will immediately impact your ED’s ability to fulfill its obligations and run smoothly.

Stay on top of the trends to know how many COVID cases are in your region to be able to better estimate the effect on the ED. There is a wealth of information available to have a precise understanding of potential influxes in patients and what types of needs they may have.

If your area is seeing an increase in COVID-19 cases, you can be more readily prepared for the effect you’ve seen it have on your ED. 

Maintain a Close Relationship With Hospital Administration

While it may seem like stakeholders and board members have the most invested in your ED’s success, it’s essential to keep a close relationship with your hospital administration to have the utmost operational efficiency. 

While your ED may have its own internal operations, streamlining the processes from within the department and throughout the hospital is crucial.

Create a comprehensive plan for how your ED will handle an increased patient load versus a decreased patient load and what to expect during each scenario. Everyone has a common goal of being efficient, helping patients, and growing available funds.

Know your numbers here as well. Work with the ED and hospital administration to use real-time data to make more educated decisions. Know what the touch-points are and how long each step of the patient intake process necessitates. From here, you can learn where your ED needs further considerations for improved productivity and better preparation for any challenges to come.

Partner With a Strong EM Billing Partner

DuvaSawko manages your ED’s revenue cycle to ensure you can recoup the most money possible.

Through identifying lost revenue, mitigating compliance risks, and increasing efficiencies to collect every dollar possible, DuvaSawko helps ensure your ED is getting the most funds feasible during this unpredictable time.

Billing collection is a constant challenge in emergency medicine, no matter what is transpiring in the world. The addition of a global pandemic creating decreased ER visits while possibly inundating other hospital units makes the collection process even more difficult.

Now, more than ever, it’s vital to streamline your practice’s efforts in collecting revenue to secure the most funds possible and remain productive. 

We have shown EM practices how to positively impact revenues by between 10 and 30% annually. For more information on DuvaSawko’s billing and coding solutions, dedicated account managers, and proprietary software solution, contact us today!

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How to Effectively Reduce ER Wait Times

The average emergency room wait hovers around 40 minutes. Here are some things your ED can do to reduce these ER wait times.

The average emergency room wait time in the United States is around 40 minutes, according to a 2017 survey published by the Centers for Disease Control and Prevention (CDC). And that’s just to be initially seen, not treated.

Reducing wait times not only allows you to assist patients with their medical needs quickly, but it also allows your emergency department staff to process more patients. 

As we go through the unprecedented effects of COVID, which has caused ER wait times to temporarily go down, this article will help you to come out better prepared on the other side once the world regains a sense of normalcy and wait times start to increase again.

We’ll discuss the reasons your emergency department may be processing patients at a slower rate. Then we’ll show you the best ways you can effectively reduce your ER wait times to not only become a more efficient emergency department but to better the reputation of your facility as a whole.

What Makes Emergency Room Wait Times Longer Than They Should Be?

Waiting is inevitable – not just at the ER. Many assume the reason for a high wait time at the ER is insufficient staffing that affects customer/patient ratios, which is usually brought on by a lack of funds.

Insurance companies and patients pay for each and every service they receive, as well as a fee for just visiting, so lack of funds that limit staffing or technology is not always the reason behind the wait times in an emergency room (assuming you’re properly collecting on these bills). So what else is?

As we know from being on the frontline, the processes in an emergency department are complex. Patients start with the triage nurses who provide an initial assessment of their symptoms and issues. The process continues with testing of basic vitals and then additional testing depending on the symptoms that brought them there.

Then the patients tend to wait because other patients need to have initial evaluations as well. The patients eventually see the doctor, and the transition between each interval is what causes such a delay. If a patient needs a bed, they must wait for one to be available, trickling down the chain and affecting those waiting for their initial screening.

Of the inpatients in the hospital on a given day, studies show that 70 percent start in the emergency room, concluding that the ER tends to be the hospital’s gatekeeper. So when a bed is not available, the ER wait times are greatly influenced.

But not having enough beds isn’t always the case. According to the same study, only 20% of emergency room visits end up admitted. So what else is causing the extended wait times?

The variability of the emergency room is the biggest culprit. While an ED can do its best to estimate the number of nurses and physicians needed to staff the department at any given time, it’s impossible to know for sure. 30% of ER visits in the United States are considered non-emergencies, which can also contribute to a higher number of patients that must go through the entire process, while they may not need much of it.

Unlike most businesses, in a hospital’s emergency room, we don’t have the luxury of defining the times in which our “customers” may show up. They come when they need to, and they arrive with a plethora of different needs, each one different from the next.

So how do we manage this?

How to Reduce ER Wait Times

It would be easy to conclude that we simply need more physicians, more beds, and faster technology to process and diagnose patients to get them on their way faster. But this can be very costly, as there is potential that these extra resources would be standing by idle much of the time, as they’ll only be needed if there is an influx of patients.

There are a few different ways we can alleviate some of this wait time in our EDs.

Study Your Data

The first step in decreasing the wait time is knowing where the waits are happening. Analyzing your intervals is a great method for determining where the process is slowing. Are patients waiting an excessive amount of time just to get to the triage nurse? Is the bulk of their delay occurring after their initial testing is complete, and they are waiting to see a doctor? 

Analyzing your other patient data is also crucial. Knowing the top reasons people visit your ER by analyzing historical coding data can help your ED to be more efficient. It’s critical to know how to leverage this data to be utilized in your favor.

Related: How to Use ER Visitation Data to Help Improve Your Group’s Efficiency

Once you understand exactly what types of cases your ER is seeing and where your gaps are can help you determine the best way to improve. And don’t just study them one time – continue to revisit them to ensure you’re doing everything you can to limit unnecessary waiting.

Engage The Whole Team

Rather than analyze processes behind the scenes, bring your entire staff on board to work on improving the wait times. 

Your nurses and physicians are the ideal people to help generate ideas based on what they see on the frontline. They’re working diligently every day, and they may be able to help propose new procedures that can increase efficiency.

Reduce Unnecessary ER Visits

The number of ED visits increased from 128.97 million to 144.82 million between 2010 and 2016 alone. More and more patients seek instant treatment and don’t prefer to wait for an appointment with their primary care – or for any required test results to come back. 

Educate patients so they understand when it’s vital to visit the ER – a broken bone, chest pain, an injury requiring stitches. Increase patient awareness about when they should choose the ER over a doctor’s appointment. 

Offering telemedicine is a great option as well. Allowing your ED to provide treatment advice virtually will free up space for more serious needs, reduce unnecessary visits, and therefore decrease your wait times.

Related: How Can EDs Reduce Visits for Non-Urgent Conditions?

Fast-Track Triage with RNs

When there is an inrush of ER patients, studies have found it beneficial to give patients access to a registered nurse in the waiting room. The RN can evaluate the needs of the patient and determine which symptoms do not warrant the need for a physician with an expert level of skill.

In a study of Hurricane Maria’s catastrophe in Puerto Rico and its effect on ER wait times, the research found that an approach where the ED employed RNs to provide an initial evaluation of patients resulted in quicker treatment and discharge.

While these are a few tips you can implement to improve your ER wait times, having the funds to employ enough staff is also crucial. Without the nurses and physicians needed to move patients through your ED’s patient process, any other efforts may not be as beneficial as they could be.

DuvaSawko is an EM Billing & Management Solution that can optimize your revenue cycles and ensure you’re collecting on your patients’ bills promptly. With an expert analysis of your practice’s performance, DuvaSawko can help reduce ED profits that may slip through the cracks, in turn increasing the available funds needed to staff your ED appropriately and reduce ER wait times. 

Don’t miss out on revenue. Contact us today. 

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How to Use ER Visitation Data to Help Improve Your Group’s Efficiency

How to Use ER Visitation Data to Help Improve Your Group's Efficiency

Do you know the top reasons why people visit the ER? Analyze your ED’s historical coding data, and you’ll find the path to higher profitability and efficiency.

How much can your Emergency Medicine practice learn from analyzing the most common reasons for emergency room visits?

Each time a patient visits your emergency department (ED), your team must select a primary reason for care from the ICD-10 emergency diagnosis codes list. This includes everything from reports of chest pain to headaches and constipation.

This data isn’t just a record of the interaction and service provided for reimbursement, it’s a wealth of information about the types of cases and patients you serve most often. 

The bad news? Most emergency medicine administrators don’t know how to leverage this data for a higher level of efficiency.

So in this quick guide, we’ll highlight recent ED-use statistics, break down the most common reasons for emergency room visits, and explain why understanding this data matters so much as it relates to your group’s efficiency. 

Trends in Emergency Room Visits Statistics and Patient Wait Times

Emergency department national benchmarks indicate that ER visits and patient wait times are both increasing exponentially.

Your ED statistics may differ due to the number of other nearby hospitals/freestanding EDs, your local payer mix, and other heavy factors. So let’s take a look at how the data is trending, on average, to assess the future of ED use and your plan to meet these demands.

Emergency Room Visits Statistics

Nationwide, recent reports show[*][*][*]:

  • ED visits grew twice as quickly as the overall population (1.7% vs. 0.7%) between 2010 through 2014.
  • Total ED use increased by 2.5 visits more in Medicaid expansion states than in non-expansion states after 2014. 
  • The number of ED visits increased from 128.97 million to 144.82 million between 2010 and 2016.

Rural and urban ED use trends highlight how administrators are struggling with above-average utilization rates and suffering lower profitability as safety-net hospitals.

Between June 2017 and November 2018[*]:

  • Rural ED visit estimates increased by more than 50% from 16.7 million to 28.4 million. That’s a leap from 36.5 to 64.5 visits per 100 persons.
  • Urban ED visits increased from 98.6 million to 117.2 million.

With all this extra foot traffic in the ED, it’s no wonder patient waiting times have also ballooned.

Emergency Room Wait Times Statistics

Overcrowding in high-traffic emergency departments leads to longer wait times and increases the chances of patients leaving without being seen.

EDs in Nebraska admit patients in under two hours, on average. Conversely, the average time (in hours) for patients to spend in the ED before being admitted is highest in these states[*]:

  1. Maryland: 6:22
  2. New York: 6:10
  3. New Jersey 5:49
  4. Delaware: 5:48
  5. California: 5:45

What about how long patients must wait in the ER before being sent home (if not admitted)? North Dakota EDs take the title here, sending patients home within 1.5 hours. But these states have the highest average discharge times (in hours)[*]:

  1. Maryland: 3:14
  2. Delaware: 3:06
  3. New York/Arizona: 2:49
  4. Massachusetts: 2:44
  5. New Jersey: 2:41

So how do emergency medicine administrators, physicians, and staff deal with extra cases, lower patient wait times, and still deliver more reimbursable care? By analyzing why everyone’s there in the first place.

15 Most Common Reasons for Emergency Room Visits

Hypertension may be the most common diagnosis in ER medicine in the US, but there’s much more intel you can glean from your patient coding data and healthcare trends in 2020.

According to historical ICD codes, the 15 most common reasons why people visit the ER include[*]:

  1. High blood pressure / chest pain / cardiovascular issues
  2. Acute upper respiratory infection
  3. Urinary tract infection
  4. Headache
  5. Abdominal pain
  6. Syncope and collapse
  7. Noninfective gastroenteritis and colitis
  8. Dizziness and giddiness
  9. Low back pain
  10. Nausea with vomiting
  11. Unspecified asthma
  12. Constipation
  13. Acute bronchitis
  14. Strain of muscle, fascia, and tendon at neck level
  15. Fever

Again, your historical coding data may differ from these averages, so it’s crucial to analyze your specific numbers to get ahead of the trends.

New research also reveals an expanding number of cases related to[*]:

Another point to remember is that ED visits also wax and wane by the seasons.

Seasonal Reasons for Visiting the ED

Issues like bug bites, allergies, plant rashes, and activity-related injuries are prevalent during summertime in the ED.

Holiday emergency room statistics during the winter months often expose higher incidents of:

  • Burns from cooking
  • Alcohol-related accidents
  • Head, lower back, and hip injuries (from slips-and-falls)
  • Food poisoning
  • Depression
  • Flu

So why is it so vital to become aware of these trends?

Why Your ED Coding Data Matters

Partner with the right revenue cycle management team, and you’ll have access to data about your ED’s usage statistics, the types of diagnoses you treat most often, where you’re spending the bulk of money on resources/staff, and more.

Understanding this intel is crucial for your emergency medicine team to:

1. Prepare for Staffing, Equipment, and Supply Needs

Research shows that visits for the five most common clinical coding categories comprise about 30% of all ED visits[*], so you may want to focus on these specific areas to increase the value of your ED care.

An exceptionally high number of cases in any particular category may justify hiring more team members, buying a new diagnostic machine, or renegotiating supply quantities/prices with vendors.

Take a deep dive into your data, and you’ll be better able to predict and prepare for whatever’s in the waiting room — ASAP. You may also take financial safeguards to protect your ED from losses due to unpredictable events or situations, such as a national disaster (i.e., hurricane, tornado, flooding, etc.) or the next coronavirus.  

Read next

Preparing Your Emergency Department for the Next Pandemic

2. Help Staff Understand Common ICD Diagnosis Codes

New emergency physicians are always taught the phrase, “When you hear hooves, think horse; not zebra.” This old adage means that your staff should be familiar with the more common reasons for ER visits rather than expecting an exotic case with a code they’ve never used before. Once they get these down, they can further refine their coding abilities to accurately reflect each case’s nuances using secondary codes.

As your physicians, nurses, and coders understand the most common ICD diagnosis codes, they’ll make fewer mistakes. This is good news for you since inaccurate medical coding and billing can lead to higher denials or medical billing fraud (which doesn’t require intent).

Read next

Consequences of Medical Coding & Billing Errors & How to Avoid Them

Denials in Medical Billing: How to Play Nice with Insurance Denials

3. Reduce Non-Urgent ED Visits

What percent of ER visits are emergencies? Unfortunately, a meta-analysis of 26 studies reveals that 37% of all ED visits are for non-urgent conditions[*].

Rural and urban EDs have the highest utilization rates because patients either don’t have access to a primary care physician, can’t make appointments with specialists, or don’t have insurance coverage. EM groups must then treat non-urgent cases, leading to higher healthcare spending and unnecessary testing and treatment costs.

You may be able to redirect non-urgent patients using options for telehealth and non-emergent fast tracks (which don’t require an ER doctor). These will save your group time and money, and better help patients in the long-term.

Read next

Unnecessary Care in Healthcare is Costing Patients $210B a Year

How Can EDs Reduce Visits for Non-Urgent Conditions?

EM Trends in Telemedicine

4. Explain Billing Concerns to Patients Early On

EDs should have a system in place to help staff and patients understand emergency medicine billing concerns early in the visit before they’re seen by a physician. 

When your team becomes familiar with the most common reasons for visiting the ED, they’ll have a better idea of how much different testing/procedures will cost patients. This should make explaining the difference between higher out-of-network ER charges and lower in-network choices easier for patients to grasp.

This step should raise your reimbursement rates and improve self-pay collections.

Read next: 3 Ways to Improve Emergency Department Self-Pay Collections

5. Lower Wait Times and Boost Patient Satisfaction Scores

Perceived wait times in the ED, more so than actual ED wait times, serve as a predictor of a very favorable ED rating and patient experience[*].

As your team becomes more familiar with assessing common complaints, they’ll know exactly how to speed your patients through triage, diagnosis, and discharge. 

Plus, once you have a solid understanding of your ED’s most commonly diagnosed codes, you could try forecasting models and simulation tools to estimate demand and reduce patient waiting times. These may help you balance your allocation of doctors to specific types of patients, or match the availability of doctors to forecasted demand patterns. You can even generate and test solutions to decrease overcrowding. 

Read next: 3 Emergency Department Operations Strategies to Improve Efficiency

Coding Stats from Your Emergency Medicine Revenue Cycle Management Provider Will Help Your ED Thrive 

Around the country, EDs are closing despite an influx of patients. Why? Because it’s hard to remain profitable when your operating costs exceed your total reimbursements. 

Analyzing and understanding your data for the most common reasons for emergency room visits will help administrators better allocate, prepare, and predict your ED’s staff and patient needs.

An experienced RCM partner will provide this vital insight and show you the daily inefficiencies affecting your emergency medicine practice. To learn where you may be losing valuable revenue, check out the free DuvaSawko Medical Billing Calculator now

Ready to touch base, ask questions, or learn more about our proprietary technology? Contact the DuvaSawko team today!

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Keeping Your Emergency Department Safe From Medical Billing Fraud

Keeping Your Emergency Department Safe From Medical Billing Fraud

Medical billing fraud carries career-ending penalties and fines. Learn from these examples to avoid healthcare billing fraud at your emergency department now:

Federal, state, and local governments have been aggressively working together to eliminate the billion-dollar medical billing fraud problem.

Rather than spending the money paying out fraudulent claims, the government is now routing their funds to seek out and bring medical claim abusers to justice.

With the increase in funds earmarked for audits and investigations, emergency medicine groups must take extra steps to avoid healthcare billing fraud at their emergency departments or face severe fines, penalties, and sanctions — including potential prison time.

We’ve discussed the consequences of medical coding and billing errors (and how to avoid them) in a previous guide; but in this post, we’ll go over the basics of medical billing fraud, cover a few examples of Medicare/Medicaid fraud, and highlight the best ways to keep your EM group safe.

Medical Billing Fraud: The Basics

Healthcare billing fraud often comes down to medical coding and compliance. Each service your team provides corresponds with its own Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System codes. Claims for services are then submitted to insurance companies, Medicare, Medicaid, etc. with these codes.

Medical billing fraud occurs when there’s evidence of misrepresentation which leads to your group’s monetary gain (or other unearned benefits) over a long period of time and across many patient records. This fraud can be inflicted upon both insurance companies and the government.

Common Examples of Healthcare Fraud

The most common examples of healthcare fraud include:

  • Kickbacks
  • Submitting false claims to CMS for payment
  • Billing for “ghost” patients
  • Billing for services not provided
  • Billing for equipment/devices not provided
  • Upcoding
  • Unbundling services for separate billing
  • Lack of medical necessity
  • Overutilization of medical procedures/services

Medicare/Medicaid Fraud and The Federal Civil False Claims Act (FCA)

Submitting false or fraudulent claims to the government (via Medicare and Medicaid), either with or without intent, violates the Federal Civil False Claims Act (FCA). Any medical provider that keeps the money paid by the government for their false claims also violates the FCA.

Federal False Claims Act (FCA) Penalties, Sanctions, and More

The penalties for violating the FCA could mean the end for an emergency physician or healthcare entity, including:

Penalty Fines

Penalties are calculated on a per-claim basis. The government can recover[*]:

  • Up to three times the amount they paid your EM group per false claim
  • A penalty of up to $23,331(as of 2020) per false claim filed 
  • A fine up to $250,000 if you knowingly falsified claims
  • Up to $50,000 per violation of the Anti-Kickback Statute – and a fine three times the amount of the kickback
  • The costs of bringing the case to trial

Permanent Medicare/Medicaid Exclusion and/or Other Career-Endings

You may be denied from ever being an approved medical provider in the Medicare/Medicaid system. Losing this over-55-million-member strong network would be a serious blow to your revenue.

You may also lose your license, DEA registration, staff privileges, and have payment for outstanding invoices suspended.

Even if you prevent exclusion during a settlement deal, you’ll still be forced to comply with continuous monitoring by the government for many years, and you’ll pay additional fines for years to come.

Imprisonment

Because the government can’t imprison a healthcare entity or corporation, individuals found committing fraud, and the individuals in control of the organization (such as a CEO, CFO, or medical director), can face criminal prosecution.

Besides the $25,000 fine, you’ll also face prison times for[*]:

  • Healthcare Fraud: Up to 10 years (up to 20 years if bodily injury was incurred)
  • Conspiracy to Commit Healthcare Fraud: Up to 20 years
  • False Claims Act Convictions: Up to 5 years per claim, or up to life if convicted of multiple claims.

When you add up all the damages and penalties per claim, it’s easy to see how violating the FCA could result in millions of dollars in restitution, bankrupt an emergency medicine group, and destroy a career. 

Despite the severe penalties for billing for services not rendered, upcoding, and other fraudulent behavior, people still continue to cheat the system.

Examples Of Medicare/Medicaid Fraud

We don’t need to name names to learn from their mistakes, but seeing these examples of Medicare/Medicaid fraud in action will show you what your EM group may be up against:

Upcoding Emergency Department Patients for Inpatient Services[*]

A former nurse alleged that her hospital and it’s owner submitted false claims to Medicare for billing for inpatient services while patients were still waiting in the emergency department. On paper, when patients get out of the ED, they can be billed for more expensive service, so administration instructed staff to “upcode as many revenue codes” as possible.

$16 Million Settlement for Overbilling Medicare/Medicaid[*]

A healthcare organization was ordered to pay $16 million to settle FCA violations in Atlanta. Case managers overruled treating physicians and billed at a more expensive inpatient rate although patients could have received less costly outpatient care. They also violated the Anti-Kickback Statute by purchasing a cardiology group above fair market value.

Tennessee Hospital Settles FCA Allegations After Self-Disclosing[*]

An internal investigation led to the discovery of a regional hospital using inappropriate codes for stroke, respiratory infection, simple pneumonia, and septicemia patients. They self-disclosed these findings to the government and agreed to settle FCA allegations for $1.7 million.

The Justice Department commended the hospital for it’s “transparency and diligence,” and the hospital has implemented new protocols to address and avoid the issue in the future.

$40 Million Medicare Device Fraud in Florida[*]

A doctor lost his medical license and was sentenced to 18 months in prison for signing orders for medically unnecessary arm, knee, and wrist braces. Though the doctor billed Medicare for the devices at a cost of $7.6 million personally, he was part of a $40 million scheme with several others.

$900 Million in Kickbacks in California[*]

The former owner of a California hospital received 15 months in prison for his role in a kickback scheme totaling over $900 million in fraudulent claims. The doctor paid physicians, chiropractors, and marketers to refer patients to his hospital for services. He forfeited $1 million to the government and paid a $60,000 fine.

Nine Physicians Charged in $2B+ Healthcare Billing Fraud Scheme[*]

Nine physicians and 26 other individuals were charged in one of the largest medical billing fraud schemes ever. According to prosecutors, laboratories paid illegal kickbacks and bribes to medical professionals working with fraudulent telemedicine companies. They referred Medicare beneficiaries for medically unnecessary cancer genetic tests, submitting over $2 billion in fraudulent claims.

The Best Ways to Help Your Emergency Department Avoid Healthcare Billing Fraud

Healthcare fraud and compliance is an ongoing challenge you’ll need to face head-on to stay ahead. These three tips may help prevent medical billing fraud at your ED:

1. Ongoing Education

Emergency physicians and staff must keep up with new rules and regulations for emergency medicine billing to ensure they’re not unknowingly miscoding claims. Medicare/Medicaid billing manuals/procedures can be overly complicated, and coding errors and simple misunderstandings could lead to adverse consequences.

However, continuing education requires a significant amount of time and energy, as does learning new emergency billing software. All of this can take away time and resources from physicians and staff that should be devoted to patient care.

2. Encourage a Safe Space for Whistleblowers

Healthcare billing fraud investigators find confidential informants via current and previous employees to assist in the gathering of evidence and prosecution. Patients and staff who file Medicaid fraud Whistleblower lawsuits may receive up to 30% of the recovered money. 

With this type of incentive, it’s important to encourage a safe space for Whistleblowers to speak up about errors or behaviors they may consider to be potential fraud. Practices may then be able to address and settle issues discreetly and with lower financial ramifications.

3. Outsource Your Medical Coding and Billing

It’s not uncommon for emergency medicine groups to outsource emergency department services like medical coding and billing, denial management, and other payment management services.

The benefits of outsourcing hospital ER billing include:

  1. Fewer errors
  2. Lower expenses
  3. Higher revenue
  4. Better cash flow
  5. Greater staff focus
  6. Higher patient satisfaction
  7. Easier adherence to compliance
  8. More consistency

But there’s a big difference when it comes to compliance between outsourcing your emergency department coding to a US-based company versus offshoring ED coding, and the few dollars you may save aren’t worth everything you may lose.

At DuvaSawko, All Our Coders Have Nationally-Recognized Coding Credentials

In the quest to make a positive impact on the US economy, DuvaSawko employs only US-based coders. We boast some of the best billing outsourcing options for EDs seeking high-quality emergency medicine revenue cycle management partners.

Our quality control and compliance program is designed to adhere to all relevant standards, ensure that staff is adequately trained, monitor the continually changing regulatory environment, and implement timely changes to maintain compliance.

As such, each of our coders is assigned to specific clients for familiarity, consistency, and service continuity. 

The National Industry Standard Benchmark For Accuracy: 3%

The Duvasawko Benchmark For Accuracy: 5%

Check out the DuvaSawko Medical Billing Calculator now to see where you may be losing valuable reimbursement dollars. Collect this money, and you can offset the cost of outsourcing your billing and also avoid medical billing fraud.

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EDs are Closing Despite an Influx of Patients. Why?

EDs are Closing Despite an Influx of Patients. Why?

Why are EDs closing despite ED visits increasing? We dive into 5 reasons hospital closures by year keep rising so you can work towards greater profitability.

Why are hospitals closing?

And more importantly, why are EDs closing?

Within the last 20 years, the annual number of emergency department (ED) visits increased by over 40%[*] and there was an average of 69 ED closures by year between 2001 and 2013[*].

Rural hospital closures by year are even worse:

  • Between 2013 and 2017, rural hospitals closed 2x more than the previous five years[*].
  • Since 2010, 113 rural hospitals have closed, mostly (77%) in southern states[*].

Emergency department closures don’t just affect emergency medicine groups and their staff. They also have a profound ripple-effect on their communities[*].

Closing an ED, especially in a rural area, increases the distance patients must travel for time-sensitive care. It also leads to overcrowding at neighboring EDs, which decreases the quality of care, adds to waiting times, and increases the rate of patients leaving without being seen.

All those factors lead to a statistically significant increase (30%) in morbidity and 90-day mortality[*].

So why are rural hospitals closing, and what’s causing these trends?

Read Next: Convenience Is Not the Only Reason Millennials are Using Urgent Care Centers More Than Emergency Rooms

Why Are EDs Closing? 5 Reasons

Smaller facilities are more likely to close due to low patient volume and a lack of steady revenue[*].

But the top five reasons many EDs are closing include:

#1. Poor Payer Mix

An emergency department’s mix of payers is the most significant factor in whether it will keep its doors open.

Federal law requires hospitals and EDs to evaluate and treat all patients needing emergency care, regardless of their ability to pay.

However, research shows EDs with a poor payer mix are notoriously unprofitable[*].

Part of this may be due to Medicaid expansion (or the vote against it).

A majority of hospitals vulnerable to closing are located in states that did not expand Medicaid under the 2010 Patient Protection and Affordable Care Act. But studies also show that expansion states experienced increased, rather than reduced, ED closure rates from 2010 through 2013[*].

So a better indication of payer mix may come down to area demographics.

After all, experts say the wealth of a community is one of the best predictors of how profitable a hospital or ED will be[*]. If the ED is located in an area with a higher cost of living and higher-than-average salaries, they’re more likely to treat insured patients or those who can self-pay.

Conversely, hospitals and EDs serving a higher share of minority, poor, elderly, and uninsured were 37% more likely to close (despite increased ED utilization)[*].

Even underinsured patients pose a risk. They often have high-deductible health plans and cannot afford to pay out-of-pocket either[*].

Read Next: 3 Ways to Improve Emergency Department Self-Pay Collections

#2. Safety-Net Status

EDs categorized by safety-net status — patient populations with a substantial amount of uninsured, Medicaid, and self-pay patients — provide a high volume of healthcare (more than 30 to 40% of visits) to vulnerable populations[*].

The estimated number of rural safety-net EDs was around 38% in 2005. By 2016, that number jumped to 65%.

With higher utilization rates and lower rates of reimbursement, these EDs face enormous pressure to remain profitable.

And that’s why research shows safety-net hospitals were 10% more likely to close than those not classified as such[*]. 

Even the cumulative probability of an ED remaining open among safety-net hospitals was about 50%, compared with 74% among non-safety-net hospitals[*].

#3. Market Competition

A hospital or ED market is delineated by a 15-mile radius. And ED markets have an enormous impact on profitability.

Research shows 34% of hospitals that closed their EDs were in highly competitive markets[*].

This includes EDs sharing their market with other EDs, for-profit or government-owned hospitals, and private practices offering outpatient care.

Large healthcare organizations are gobbling up smaller operations via mergers and acquisitions to gain market dominance. By joining the competition rather than fighting it, they can offer more advanced services and charge higher prices[*].

Read Next: Do You Work in One of the Worst Healthcare States?

#4. Physician Shortages, Especially in Rural Areas

Just 4% of physicians work in emergency medicine, but they provide more acute care to Medicaid beneficiaries and the uninsured than the rest of America’s doctors combined[*].

This is particularly true in rural areas. 

Even though 20% of the U.S. population lives in rural areas, only 9% of primary care physicians practice there[*]. This forces many patients to use the ED for routine or non-emergent visits.

But that’s not what your highly-skilled EM physicians want to take care of. 

Added stress due to overcrowding, high caseloads, lower salaries, and unpredictable schedules mean that many emergency medicine groups struggle with recruiting and retaining their staff.

A shortage of physicians means longer wait times and fewer patients being seen. It also means you may be spending more on payroll than you’re bringing in via reimbursements.

So attracting and keeping physicians will allow EDs to treat more patients and generate more revenue.

Read Next:

#5. Slim Profit Margins

Did you know that unnecessary care in healthcare costs $210B a year?

Your team may be unknowingly burning money when ordering unnecessary testing and diagnostics you won’t be reimbursed for. And you may be spending more in supplies than you realize.

Studies show the decision to close an ED is generally based on the total profit margins for the three previous years. 

In this case, the total profit margin is defined as the ratio between the net revenue (total revenue, including disproportionate share (DSH) payments, minus total costs) divided by the total costs[*].

So according to stats[*]:

  • Twice as many hospitals that closed their EDs were in the lowest quartile of the profit margin distribution.
  • EDs at hospitals with negative profit margins had a 50% cumulative probability of remaining open.

Hospitals and EDs often operate on very tight margins. But if your margins are so slim they can’t account for an unforeseen expense, you may be in serious trouble and have no option but to close.

What happens if you encounter plumbing problems or structural damage from a natural disaster?

Your ED may need to close for a few weeks or a few months. Would you have enough to cover this loss of revenue?

Many hospitals simply don’t.

The Biggest Reason EDs are Closing? Not Enough Money

While each independent emergency medicine group deals with problems unique to its location, payer mix, and business model, in the end, staying open all comes down to having enough money.

DuvaSawko’s proprietary billing software and Practice Monitor analytics are designed to measure and ensure that every possible dollar is collected, preventing any collectible revenue from slipping through the cracks.

Reimbursements are received faster and more accurately than ever. DuvaSawko collects 30% more for clients, on average, to make sure you’re not leaving money on the table.

Analyzing these trends in ED closures may help your emergency department stay profitable. And our revenue cycle management services include tailored technology to grow your business the smart way.

Click here to find out where you may be losing valuable reimbursement dollars!

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Preparing Your Emergency Department for the Next Pandemic

Preparing Your Emergency Department for the Next Pandemic

Learn how emergency medicine groups are evolving their protocols to protect staff, patients, and revenue during the coronavirus (COVID-19) crisis and beyond in this guide.

How prepared was your emergency medicine group to handle the current coronavirus (COVID-19) crisis?

With healthcare providers on the front lines, hospitals and emergency departments are facing shortages in personal protective equipment (PPE), medical supplies, staff, and more.

Before the pandemic, a 2011 study published in the American Journal of Disaster Medicine revealed that[*]:

  • Just 42% of healthcare workers felt that their ED was prepared for a pandemic disease outbreak.
  • Only 68% of EDs actually have a plan for pandemic influenza response and other infectious disease threats.
  • 63% said their ED had a plan for the distribution of vaccines and antivirals, but only a scant 32% had a plan for the allocation of ventilators.

Though we expect these stats to change dramatically as a result of the COVID-19 learning curve, they don’t inspire much confidence as they currently stand.  

So learning from these impacts may be the best way to create a plan to combat them in the future.

What Can Independent Emergency Departments Learn from the COVID-19 Crisis?

Preparing your emergency department for the next pandemic isn’t just about freeing up bed capacity and creating a separate entrance for patients with the virus.

You also need to plan for your financial health. 

As we saw, stock prices for major hospital systems fell significantly with each coronavirus-related market crash. So independent emergency medicine groups may be feeling the financial strain more than ever.

Shortages in medical supplies as a result of this pandemic, and the surge in prices, may be the most frustrating and unanticipated part for healthcare providers. Yet even this may be preventable in the future.

It will take a lot more time and data retrieval to fully understand the global implications of COVID-19. 

But for now, emergency departments are being advised to begin preparations using a model that’s been studied extensively for decades (and that seems similar to coronaviruses): pandemic influenza.

How to Prepare Your Emergency Department for the Next Pandemic

With already-limited resources as a result of COVID-19, you may not even be thinking about how to prepare your emergency department for the next pandemic.

But decision-makers at all levels should be actively drafting protocols to handle the most common issues faced during these times, such as:

  • Preventing your ED from becoming a disease amplifier
  • Protecting your healthy staff and non-infected patients
  • Testing and treating infected patients safely
  • Minimizing potential financial losses

So follow these eight tips to help your emergency department plan for the future:

1. Create a Dedicated Pandemic Task Force

It’s imperative to set up a group of administrators and healthcare staff dedicated solely to pandemic preparedness and response.

This group of decision-makers will develop processes and procedures to oversee a broad range of potential impacts to the ED and anticipate resource needs.

Specifically, consider designating a/an:

  • Emergency Manager in each ED. They’ll be responsible for communicating and spreading the committee’s decisions to the staff at their local emergency departments.
  • Infection Prevention Practitioner to educate, train, and perform exercise drills with the staff and teach them the best safety practices for wearing PPE.
  • Administration Rep to discuss the financials during these meetings.

This team should be comfortable creating policies and using predictive modeling tools to help them make decisions.

2. Take Advantage of CDC Pandemic Modeling Tools

The CDC’s pandemic influenza preparedness efforts include ongoing surveillance of human and animal influenza A viruses, risk assessments of influenza A viruses with pandemic potential, and the development and improvement of preparedness tools that can aid health practitioners in the event of an influenza-like pandemic.

Emergency departments using modeling tools like these should have a better grasp on the potential impacts a pandemic worse than COVID-19 may bring. Once your team understands these projections, they can better prepare for the unexpected.

Below are a list of helpful resources:

Your team will also be able to save money by making informed decisions regarding resources ahead of time instead of at the last minute.

3. Implement a Regular Stockpile of PPE and Other Necessary Supplies 

COVID-19 created a surprising shortage of medical masks, soap, antibacterial hand sanitizer, and more in a very brief timespan. 

So while your ED may not have been stockpiling these in the past, you’ll want to start regularly ordering a bit more to fill up your reserves for next time.

This includes buying extra:

  • Surgical masks for everyone entering your emergency department.
  • N95 respirators for healthcare workers in direct contact with potentially-infected patients.
  • Powered Air-purifying Respirators (PAPRs)
  • Gloves and gowns
  • Disinfectants and sterilizers 
  • Medical supplies

Try to stock up at least three weeks’ worth of supplies in case re-supplying becomes difficult during the pandemic (as it did during COVID-19). Ideally, you should have enough to get your ED through an outbreak lasting several months.

Purchase a bit more than you need in each order, and you may even save money over the long-haul as prices soar later in a limited supply/high demand market.

These stockpiles may also give your physicians and staff more confidence to continue working.

4. Take Care of Your Staff

Your healthcare workforce is essential yet may be significantly reduced during a pandemic.

Depending on the severity of the virus, your staff may not want to risk coming in contact with infected patients and bringing it home to their relatives. They may also need to take care of sick family members or stay home with kids when schools are closed.

So have your team come up with ways to offer your staff daycare for healthy children or medical care for their sick relatives (with screened caretakers). 

These incentives may help your ED maintain or even stretch your workforce to handle the potential influx of patients.

From an administrator POV, you may also want to:

  • Schedule longer/overtime shifts to limit the amount of staff needed and prevent exposure to the majority.
    • Cohorting, or keeping dedicated staff in specific pandemic units to limit the number of those who are exposed. Staff outside this area will take care of non-infected patients in the rest of your ED.
  • Track staff symptoms. You don’t want infected staff spreading the virus to healthy patients. Yet staff who are immune or recovered make the best choice for treating infected cases. So watch for symptoms, keep testing employees, and log confirmed cases.
Preparing Your Emergency Department for the Next Pandemic

Certain employees may be better off working from home — just like some of your patients are better off using telemedicine instead of the emergency room.

5. Establish Protocols for Employees to Work Remotely 

As social distancing becomes more natural, businesses are learning that switching to a remote workforce actually saves them money and boosts productivity while protecting their staff.

Your physicians may not be able to work from home, but your revenue cycle employees certainly can. All coders, transcriptionists, etc. need is a secure computer and a stable internet connection to get their work done. 

So rather than this critical segment either risking exposure or taking time off, your ED will continue to generate income while they work remotely.

Create a remote work policy for these telecommuting employees which will include protocols for:

  • Daily check-ins with supervisors
  • Messaging procedures (such as being available via phone, email, Slack, or Skype)
  • Employee workloads, work times, and productivity goals 

6. Turn to Telemedicine 

Your patients should also consider a virtual option if they can avoid your emergency department.

During a pandemic, telemedicine gives patients a safer route when they have questions or need advice. Set up your telehealth options, and you’ll reduce non-urgent emergency room visits, decrease patient volume, and lower potential spreading.

In the wake of COVID-19, President Trump enacted an $8.3 billion emergency funding measure which lifted restrictions on telehealth services for Medicare beneficiaries[*]. 

Now physicians can get reimbursed for video visits with patients, thus driving revenue which may be slipping during the pandemic. 

Read next: Emergency Medicine Trends in Telemedicine

7. Partner with the Right Emergency Medicine Revenue Cycle Management Specialists 

No one can predict whether your ED will be the only place patients will need to go during a pandemic, or one to be avoided (like it is with COVID-19). This uncertainty and lack of emergency department use may cause a sudden dip in your revenue. 

That’s why it’s so important to partner with an experienced revenue cycle management team. Optimizing your collections will help your ED stay open so you can keep treating patients (and continue to bring in revenue). You can then allocate this money for your future pandemic preparations.

Plus, expert billing partners will keep your emergency medicine group in compliance with all the changing emergency medicine billing and coding practices that arise during a health crisis.

The Centers for Medicare & Medicaid Services (CMS) just released new billing and coding rules for COVID-19 testing and treatment[*]. These cover everything from virtual visits with a physician to isolated or quarantined private rooms if infected beneficiaries need to stay.

The last thing your team needs during a pandemic is new rules to follow. So it may be wise to outsource this task to those who specialize in it.

Read next: The Consequences of Medical Coding Errors (+ How to Avoid Them)

Collect Every Last Cent with DuvaSawko, and Prepare for Uncertain Futures with Less Stress

It’s challenging to prepare for a pandemic when the current COVID-19 crisis may be draining your resources. But many of these tips require substantial time to implement, which means your emergency department should begin preparing for them now.

So don’t leave any more money on the table.

Check out the DuvaSawko Medical Billing Calculator, and find out where you may be losing valuable reimbursement dollars. All you have to do is plug in some information about your emergency medicine practice and your payer mix.

With these extra funds, you’ll be able to prepare your emergency department to better handle dips in revenue, supply shortages, and everything else a global pandemic brings.

Talk to the team at DuvaSawko today and schedule your complimentary practice analysis.

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Lockboxes vs P.O. Boxes: What’s Better for Revenue Cycle Management?

Revenue Cycle Management

Do the benefits of a P.O. box outweigh those of a lockbox? Learn more about lockbox processing and the best choice for your emergency department’s revenue cycle management now.

Revenue Cycle Management

Is your emergency medicine group using a lockbox or a P.O. box for your revenue management?

Both processing methods ensure a safe, secure, confidential way for your patients and their insurance companies to mail their payments to your group.

But is one option better than the other when it comes to your bottom line and compliance records?

This guide covers the differences between both options, including the downsides and benefits, so you have everything you need to make the best choice.

What’s the Difference Between a Medical Lockbox and a P.O. Box?

Choose a post office (P.O.) box, and your group will have a dedicated mailbox at the post office where someone from your team will need to unlock the box, pick up the checks, deposit them, and record the payment.

Go with a lockbox service, and your bank or financial institution will offer your group a secure mailbox and the means to collect and process patient checks for you. Bank employees will deposit those checks into your account, making for a smooth transaction.

Though they seem similar, each option offers unique advantages and downsides you’ll need to weigh.

Lockbox Pros and Cons to Consider for Revenue Cycle Management

There are a few major perks when it comes to using lockboxes, but that doesn’t mean this service is perfect:

The Benefits of Lockboxes

Live check funds funds are available sooner. Since payments are collected by bank employees and deposited into your account quickly, your team has quicker access to revenue earlier.

Saves your team time. Employees no longer have to collect payments, and on rare occasions prepare deposit slips, and take a trip to the bank to add money to your account. This saves your team time and streamlines the revenue collection process.

Revenue Cycle Management

Lower chances of revenue loss. Since your employees won’t be handling the majority of your checks, your group may reduce the chances of theft or accidental mishandling.

The Downsides of Lockboxes

They can be expensive. The features offered by lockbox providers sound nice, but they come at a hefty price. Besides the typically high setup fee, your group will also need to pay monthly maintenance fees.

Many lockboxes also charge on a per item basis, which means your costs could quickly escalate.

Groups with higher amounts of small checks may rack up expensive service bills ranging in the thousands, which may minimize profit.

It doesn’t account for all revenue collection. What happens when you hire a lockbox service and also collect checks in-house at the time of service?

Your team still has to make out deposit slips and visit the bank to deposit the checks. So if you choose a lockbox service, you’re only shaving off a portion of your deposit load.

Revenue Cycle Management

Increases the risk of double-billing. Your team members have to post the payments the day after they’re deposited. But your bank sends you the slips the next day, not the day of.

If those posted checks are a day or more late, you’ll risk double billing both insurance carriers and patients alike.

Do this and you’ll run into compliance issues and frustrations from both parties.

Greater potential for errors. You should ask your bank which team members work on your lockbox in particular.

It’s often bank tellers with the least experience and seniority who work on these tasks. While that may be great for the bank, it’s risky for your payment collection.

These employees also deposit a high volume of checks at once, which only increases the margin for error.

Because of this volume, some lockbox services use offshore contractors, adding to the riskiness of their service.

Without really knowing who’s working on your payment collection, you may be susceptible to fraud from an unethical employee or contractor.

Now that you understand both the good and bad qualities of lockboxes, let’s go over P.O. boxes.

P.O. Box Pros and Cons to Consider for Revenue Cycle Management

P.O. boxes have more upsides than downsides for your emergency medicine group:

The Benefits of a P.O. Box

Cost-effective yet secure. Despite the low cost, you’re still getting a safe, highly controlled place to collect your payments with a P.O. box. You need a key to access your P.O. box, and most boxes are monitored on security cameras.

Compared to leaving checks in your office mailbox or on a desk, which can tempt unethical employees or fall through the cracks, a P.O. box may be a smarter choice.

Timely. You’ll typically get your mail sooner with a P.O. box than with a lockbox. Some locations post mail as early as 11 am or noon.

This means you won’t have to wait for your bank to collect and deposit all of the other lockboxes first before getting access to your checks.

Revenue Cycle Management

The Downsides of a P.O. Box

You must keep up with deliveries, or your mailbox could overflow and prevent you from receiving future checks on time.

It requires someone you trust. You’ll need an employee to keep track of the mailbox key, physically go to the post office to retrieve your checks, and not lose either along the way. 

As you can see, P.O. boxes have fewer drawbacks; their most significant obstacles are easy to overcome with the right partner in revenue cycle management.

The DuvaSawko Upgrade to Your Payment Collection Process

We’re big fans of the P.O. box here at DuvaSawko. We saved one of our clients a whopping $45,000 a year just by switching to one! 

Interested in what we can do for you? 

DuvaSawko handles the inconveniences and security issues that dissuade groups from using a P.O. box, and this service is popular with many of our clients.

Here’s how it works:

Instead of sending one of your team members to your P.O. box, we send one of our employees.

He or she will place the contents of your P.O. box in a specific locked bag for transport. Your bag gets delivered directly into the hands of another trusted member of our team — not left somewhere on a desk.

Revenue Cycle Management

Once your checks are accounted for and deposited, they’re placed in a secure and locked filing cabinet that only a few team members have access to.

The benefits of the DuvaSawko P.O. box payment collection process include:

  • Easy transition. You don’t need to switch from the P.O. box you’re already using. You can also incorporate this service into your existing revenue cycle management processes.
  • Accountability. We carefully monitor the chain of ownership to ensure none of your payments slip through the cracks.
  • Fewer potential errors. We use different team members to batch and balance your payments to minimize mistakes.
  • Added security. We retain copies of your checks in a secure SOC 2 compliant digital file that’s only accessible by individuals working on your account.

And that’s just the start of how DuvaSawko can help with your payment processing.

You can learn more about our payment and refund services by visiting this page now.

Lockbox vs P.O. Box: Which is Right for Your Revenue Cycle Management?

You may have a clear winner in mind after learning about the differences between a lockbox service and a P.O. box. 

Your emergency medicine group will pay extra to use an antiquated lockbox service, and the stack of downsides may be more of a hassle to deal with.

If you’re already using a P.O. box, or thinking about switching to one after the headaches of your current lockbox provider, consider partnering with DuvaSawko. Our service captures all the benefits of a P.O. box and minimizes the few downsides.

Want to talk numbers? Get in touch with us today, and we’ll help you determine which option is best for your revenue cycle management needs.

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Freestanding Emergency Departments: Reimbursements & Patient Costs May Surprise You

Freestanding Emergency Departments Reimbursements & Patient Costs May Surprise You

Freestanding emergency departments may increase utilization rates and emergency medicine reimbursement. Others say they’re raising emergency department costs and should face regulation.

Freestanding Emergency Departments Reimbursements & Patient Costs May Surprise You

Do freestanding emergency departments increase emergency visits or alleviate overcrowding at traditional emergency departments?

The annual number of emergency department (ED) visits rose by 18.4% between 2006 and 2014[*]. So many providers in populated states have decided to meet this increase in demand by opening freestanding emergency departments (FrEDs). But is this trend in ED and FrED use a good or bad thing for insurance providers?

Freestanding Emergency Departments (FrED): by the numbers

More than half of FrEDs (54.2%) are owned by a parent hospital (known as a “satellite”), 36.6% are independent, and 9.2% are not classifiable(*)(*). There are over 350 FrEDs across 30 states(*). And over 90% of FrEDs are located in urban as opposed to rural areas(*). 

Freestanding emergency departments are convenient alternatives to hospitals that help relieve overcrowding and reduce wait times. However, those against them say the cost of doing so isn’t worth the expense.

Do FrEDs Increase or Decrease Emergency Department Costs or Emergency Medicine Reimbursement?

One study analyzed the relationship between the number of FrEDs and overall spending for emergency care[*]. Researchers compared data from EDs in 495 different local markets in Arizona, Florida, North Carolina, and Texas. People in these markets are getting more FrEDs in their areas than others.

They assessed claims and usage to find total spending on emergency care, out‐of‐pocket expenses, utilization, and price per visit from January 2013 to December 2017. 

They learned that having a FrED in the area, or having another one enter the market, was associated with a/an:

  • Increase in emergency department utilization in Texas, Florida, and Arizona between roughly 3% and 5%. Another study showed freestanding ED utilization in Texas alone increased by 236% between 2012 and 2015(*).
  • Increase in emergency provider reimbursement per insured beneficiary by 3.6% in three out of four states (Texas, Florida, and North Carolina). 
  • 3.6% increase in estimated out‐of‐pocket spending per beneficiary in Texas. Keep in mind that spending per enrollee is also much higher in Texas than in other states studied. During the trial, spending per enrollee in Texas grew from $132 to $216, and out-of-pocket costs jumped from $54 to $72. Mean spending per enrollee in Texas was more than twice as high as other states in the study[*].
  • 15.3% reduction in out‐of‐pocket spending per enrollee in North Carolina.
  • 10.1% decrease in the price per ED visit in Arizona.

This data suggests freestanding emergency departments increase local market spending for emergency care in 75% of markets they enter. But this modest rise in spending matched the emergency medicine reimbursement rate. This suggests insurance providers are covering the higher costs associated with FrED usage. But how long will they continue to pay these higher-than-average bills?

And will it continue long enough to help patients decrease medical bills like FrEDs in states like North Carolina and Arizona did?

How to Keep Your ED or Stand-Alone Emergency Department On Everyone’s Good Side

In June 2018, The Medicare Payment Advisory Commission recommended reducing Type A ED payment rates by 30% for satellite EDs within six miles of a hospital‐based ED. MedPAC believes that the current Medicare payment system incentivizes providers to treat lower‐intensity patients in the ED rather than in urgent care centers, which are paid less than half the Type A payment rates for ED services[*]. 

As more FrEDs open, legislation may standardize care or covered services so the use of them doesn’t skyrocket insurance prices. Here’s what EDs can do in the meantime:

Stay competitive. Patients will soon get to price services and compare their options for care. 

In Arizona, aggressive price competition ultimately saved patients and insurers over 10%[*]. Transparent pricing online may save patients and insurers money so reimbursements continue. Aggressive price competition ultimately saves patients and insurers money so they continue to reimburse independent EDs. Patients should know they’re paying a premium at a FrED and understand that they may not receive the lowest cost care.

Post your in-network and out-of-network policies. In-network EDs provide patients with lower prices for services. But most FrEDs are usually out-of-network for patients, which costs them much more. Be as transparent as possible to avoid surprise medical bills and tanking self-pay collections.

Freestanding Emergency Departments Reimbursements & Patient Costs May Surprise You

Reduce expensive visits and facility fees. A recent study found that prices for patients with similar diagnoses were ten times higher at FrEDs in Texas compared to urgent care clinics[*].   

Researchers theorized that if insurers and FrED owners could reach an agreement to reduce facility fees for patients with non-emergent conditions, patients could receive timely and affordable access to care while FrED operators could still earn revenues for filling an unmet need in the market.

Inform patients about alternative care in lower-cost settings at a doctor’s office or traditional ED. Most patients don’t know FrEDs charge a facility fee for each visit. The facility fee originated under the Medicare program and was intended to compensate hospitals for the operational expenses of maintaining an outpatient facility(*). However, facility fees are also charged to patients with private insurance coverage much to their surprise(*). Retail and urgent care clinics and doctors’ offices do not charge this fee.

Despite freestanding EDs increasing local market spending, they can also increase utilization rates and even lower the price of ED visits. 

To gauge the competitiveness of your ED for your market area, click here for a complimentary practice analysis from the experts at DuvaSawko now!

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Consequences of Medical Coding & Billing Errors & How to Avoid Them

Consequences of Medical Coding & Billing Errors & How to Avoid Them

Medical coding errors lead to higher claim denials, loss of revenue, and federal penalties, fines, and imprisonment. Learn how to protect your emergency medicine group from ED coding errors now:

Consequences of Medical Coding & Billing Errors & How to Avoid Them

Are the consequences of inaccurate coding and incorrect billing drowning your emergency department?  The fact is, a lot of groups don’t know the extent of the damage it’s having on their groups until, unfortunately, it’s too late!

Basic medical coding errors have the potential to cost your emergency medicine practice hundreds of thousands or more in lost revenue. When the government and insurance companies deny claims with medical billing and coding errors. Your EM group loses reimbursement revenue until you can correct and resubmit a clean claim.

The most common medical billing and coding errors lead to high denial rates and may compromise patient care. But the more serious consequences of upcoding and acts of medical abuse and fraud could have your group facing federal penalties and expensive fines.

So it’s time to start eliminating your medical coding errors, lower denials and rejected claims, and maximize your reimbursements. And it all starts with a basic understanding of why this all matters so much.

Why is Medical Coding Important?

Medical coding is how your practice turns the services you provide into billable revenue. Each service corresponds to its own Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System codes. Claims for services are then submitted to insurance companies, Medicare, Medicaid, etc. with these codes.

Consequences of Medical Coding & Billing Errors & How to Avoid Them

Inaccurate medical coding will cause your reimbursements to get delayed, denied, or only partially paid. Build up a cache of delayed reimbursements and you’ll have mounds of paperwork, stress, and lost revenue for your emergency medicine practice to deal with.

Miscoding a procedure may mean the difference between $15 and $15,000. But it’s not only about the money.

What are the Most Serious Consequences of Inaccurate Coding and Incorrect Billing?

Have a history of incorrect coding and emergency medicine billing mistakes? Your emergency medicine practice may come under intense scrutiny for medical fraud and abuse[*]. And then you’ll  could be facing serious federal penalties and fines.

Medical abuse happens when your team falsifies claims that lead to your practice’s monetary gain, either deliberately or unintentionally. Medical abuse is considered fraud when there’s evidence of intentional misrepresentation over a long time and across a large number of patients.

Consequences of Medical Coding & Billing Errors & How to Avoid Them

Submitting incorrect claims to the government (for Medicare or Medicaid) violates the Federal Civil False Claims Act (FCA). The law does not require intent, so mistakes can be costly.

Civil penalties for violating the civil FCA may include recovery of up to three times the amount of damages sustained by the Government as a result of the false claims, plus penalties up to $22,927 (in 2019) per false claim filed[*]. Defraud any government healthcare benefit program and the penalty can even include imprisonment. 

Terrifying as those are, the most common consequence of medical coding and billing errors is not having your claims reimbursed by the insurance companies.

Reasons that Claims Could Be Returned By the Insurance Companies

New, confusing codes within the ICD-10 can create short- and long-term revenue issues if your team doesn’t keep up with the changes. What’s the difference between a denied claim and a rejected claim?

Insurance companies say a denied claim is unpayable. The reasons for denial can include billing errors, missing information, inadequate patient coverage, and more. Your practice will typically receive an Explanation of Benefits (EOBs) with the reason for the denial. Denied claims may be appealed and reprocessed in certain cases.

Rejected claims can be corrected and resubmitted for processing with the insurance company. Claims are most often rejected due to billing and coding errors. But once your team fixes those errors, you can resubmit a clean claim for payment again.

Your emergency medicine group will notice a boost in revenue by following up on your medical denials. And the more you correct, the more you may notice common patterns of medical coding errors surfacing.

The 8 Most Common Medical Coding Errors and How to Prevent Them

Every piece of your claim has to be accurate for a smooth reimbursement. But your team may be committing a few of the most common medical coding errors intentionally or unknowingly, including:

1. Sloppy documentation. When physicians or other healthcare providers turn in sloppy paperwork, it’s difficult for medical billing specialists to assign the right codes and bill patients correctly. Misreading handwriting errors may also contribute to undercoding (another lost revenue stream). 
2. Hurried intake/missed information. Entering incorrect information for providers, patients, and insurance providers is a top mistake. Especially in emergencies, this information can take a backseat in a panicked moment and cause an issue down the road.
3. Unbundling. Using separate codes for linked procedures when there’s a single code for the whole group of procedures is known as unbundling. This illegal act increases the total claim amount (and inflates your profit).
4. Upcoding. Upcoding happens when your team uses a billing code for a more complicated or expensive service than what was actually done. This also includes tests done by techs being coded as performed by physicians. Since more serious codes demand higher payments, this illegally inflates your revenue too.
5. Undercoding. Undercoding happens when patients are not billed for all the treatment or services rendered. This suspicious practice may help a patient avoid a high-cost bill or help your emergency department avoid audits. It also costs your EM group money.
6. Duplicate billing. This occurs when your staff bills the same patient for the same service multiple times though it was only performed once. 
7. Overusing the modifier 22-increased procedural services. Using this means the patient’s procedure required more work than normal, which would come with an increase in price. This needs proper documentation to prove/get approved.
8. Improper infusion and hydration codes reporting. To bill for these services without a denial, you’ll need accurate documentation for start and stop times.

These are just a handful of the most common medical coding and billing errors. Any of them could be the reason why your denial or rejection rates remain high. But they don’t have to be a thorn in your side forever.

How To Correct Medical Billing Errors Before they Happen

The best claims management software not only provides real-time clean claims stats but also boasts intelligent features to spot mistakes before claims are submitted and denied. Investing in software like this should be your first priority. Then your emergency medicine group should:

Train Your Team On The Most Common Medical Claim Denial Reasons

It takes a watchful eye to avoid most medical billing errors before they leave your department. Here’s a list of denials in medical billing you can avoid with strict due-diligence:

  1. Missing information
  2. Service not covered by payer
  3. Duplicate claim or service
  4. Service already adjudicated
  5. Limit for filing has expired

Additionally, it’s imperative to continue training for your team since medical billing codes change all the time. This will help them stay up to date on the latest and most specific codes to use. And it will also lower your denial rate.

Maintain a Low Denial Rate

Your emergency medicine group’s denial rate shows how much more profitable you should be. It’s also a reflection of your Revenue Cycle Management process.

Maintaining a low denial rate takes a ton of work, especially with all the constantly changing regulations, rules, and medical billing codes. If you’re not keeping up with your denials, you may consider hiring in-house staff to help. But outsourcing this task to experts who specialize in medical billing will be more cost-effective.

Outsource Emergency Department Billing and Coding

Medical coding is an immense amount of work for even the most experienced teams to handle. Small errors here and there have the potential to cause major damage. That’s why many groups outsource emergency department services.

The benefits of outsourcing hospital ER billing include:

  1. Fewer errors
  2. Better focus for your staff
  3. Lower expenses
  4. Enhanced patient satisfaction
  5. Better cash flow
  6. Higher revenue
  7. Easier adherence to compliance
  8. Greater consistency

You’ll also receive comprehensive services to handle the nuts and bolts of the billing process from beginning to end. Hand off this chore to the experts and you’ll decrease insurance denials and boost your cash flow. Then you can get back to running your emergency department. 

However, not all medical billing services are created equally.

Beware the Significant Negative Impact of Offshoring Your ED Coding 

There’s a critical distinction between outsourcing — contracting work to an external, specialized organization — and offshoring — getting work performed in a different country.

Despite the competitively low prices, offshored medical billing and coding partners are much less likely to be in compliance than those based in the US. And that puts your practice at risk. 

There’s a strong correlation between improper evaluation and management (E/M) claims being paid in error than other Part B services with offshore partners. According to a Department of Health and Human Services report, Medicare inappropriately paid almost $7 billion for improper coding or claims with lacking documentation in 2010[*]. 

This has resulted in the Department of Health and Human Services publishing recommendations that include the following[*]:

  • Physicians being better educated on coding and documentation requirements
  • Erroneous claims for E/M services followed up on
  • Physician groups encouraged to have contractors review E/M services billed for by high-coding physicians
Consequences of Medical Coding & Billing Errors & How to Avoid Them

Inadequate regular compliance oversight is a contributing factor here. But rather than hold your practice at the whim of a discount coding and compliance contractor to save a few dollars month-to-month, think of your long-term goals as a sustainable and compliant provider to ensure accuracy and profitability now and into the future. 

Practices should have professionals in place who are aware of the ever-changing compliance rules, and audits should be performed regularly. If you outsource coding already, ask your billing and coding partner the hard questions to determine if they meet the recommendations set forth by the Department of Health and your personal scrutiny.

See What DuvaSawko Can Do For Your Emergency Department’s Medical Coding and Billing Errors

Today’s independent emergency groups are tasked with more challenges than ever. Handling increasing operational costs, decreasing reimbursements, and fewer opportunities for expanding revenue sources are just a few of your daily stresses.

So why add keeping up with the ever-changing medical codes and required documentation to your plate? Or allocate expensive in-house resources to follow up on denied and erroneous claims?

Inaccurate coding leads to inaccurate reimbursement, and in some cases, legal action against your practice.​ The best way to avoid the consequences of medical coding and billing errors is to partner with a team of experts that specializes in emergency medicine revenue cycle management.

Our team at DuvaSawko minimizes errors while maximizing reimbursements. We have a 99% success rate in overturning denials and collect 30% more for our clients, on average. 

In our quest to impact the US economy, all our coders are US-based DuvaSawko employees. We don’t use contractors of any kind to get the job done. Our quality control and compliance program was designed to adhere to all relevant standards, ensure staff is properly trained, monitor the constantly changing regulatory environment, and implement timely changes to maintain compliance. 

See what our team at DuvaSawko can do for your emergency medicine group today. Contact us at 888-311-8760. Or click HERE to receive your complimentary practice analysis now!

Subscribe To The DuvaSawko Blog

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start an emergency department medical practice - 6 easy steps

DuvaSawko

start an emergency department medical practice – 6 easy steps

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