Case Study
Challenge Over Coding

Client Overview

The client is a mid-sized healthcare provider specializing in primary care services. They were experiencing significant delays and denials from Blue Cross Blue Shield (BCBS) insurance due to repeated requests for medical records with every claim submission. This issue impacted their cash flow and caused administrative burdens on their billing team.

Challenge

The primary challenge was the high rate of claim denials from BCBS. The insurance company requested medical records for every claim, which considerably slowed down the reimbursement process. Upon investigation, it was found that the claims were being submitted with a high level of Evaluation and Management (E&M) codes, which was flagged as incorrect by BCBS. This situation highlights the importance of accurate medical billing RCM practices to mitigate such issues.

Coding Denials

Blue-Cross-Blue-Shield

Decreased Revenue

Our Solution

Reviewed & Analyzed Claims

We carefully examined the claims submission process to identify the root cause of the issue.

Training & Education

Provided targeted training to the coding and billing team on proper coding practices, specifically focusing on the appropriate use of E&M codes.

Reviewed & Analyzed Claims

Implemented new coding protocols to ensure that claims were submitted with accurate E&M code levels.

Claims Resubmission

Assisted the client in resubmitting previously denied claims with corrected E&M code levels.

Solution Image

Results Achieved

Reduction in Denials

The rate of claim denials from BCBS dropped by 80% within three months of implementing the new coding procedures.

Faster Reimbursements

The average time for claims processing and reimbursement decreased by 50%, significantly improving the client's cash flow.

Increased Efficiency

The administrative burden on the billing team was reduced, allowing them to focus on other critical tasks.

Compliance & Accuracy

Enhanced the accuracy of coding and compliance with insurance requirements, reducing the risk of future denials and audits.

Reduction In Denials
0%
Faster Reimbursements
0%
Increased Efficiency
0%
Compliance & Accuracy
0%

Conclusion

By identifying and correcting the coding errors related to E&M code levels in medical billing, we were able to streamline the client’s claims submission process, significantly reduce denial rates, and improve reimbursement times. This case highlights the importance of accurate medical billing coding and ongoing education for billing teams to ensure compliance and optimize revenue cycles. Our tailored solution not only resolved the immediate issue but also positioned the client for long-term success with more efficient and effective medical billing practices.
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