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Enhancing billing accuracy with provider education

Without ongoing guidance, it can be challenging for providers to navigate a complex billing ecosystem. And the billing errors that result can also be costly. On average, health plans and providers spend an extra $31 to manage a denied claim.1 The Centers for Medicare and Medicaid’s 2021 CERT Improper Payment Study showed improper payment rates of 6.31% and 8.49% for Part A and Part B providers, respectively.2 To reduce overall medical and administrative costs and ensure compliance, health plans need to prevent repeated high-volume, low-dollar billing errors. At the same time, they need to be at the forefront of identifying unusual billing trends. One of the most effective ways to reduce these errors, without causing provider abrasion, is to change provider billing behavior through education. Education can empower providers to correct billing errors before they submit a claim. This helps improve first-pass adjudication rates. It also helps reduce denials, appeals and medical record requests.

Identifying opportunities for education

What’s the best way to educate providers on billing essentials? First, it’s important to take individual provider billing patterns into account. The root cause of billing errors will vary from provider to provider, so a targeted education program will be more successful than a one-size-fits-all approach. Analyzing provider billing errors is a good way to uncover opportunities for education. This analysis will help a health plan determine which providers could benefit from education and what topics they need guidance on. Segmenting your audience will help you target providers with the right topic at the right time. This leads to more impactful behavioral change. In addition to audience segmentation, a comprehensive education program should use both high-touch and low-touch tactics. This will allow health plans to meet providers in their channel of choice. It creates multiple touch points to reinforce an educational message and maximize positive behavioral change.

Common education topics

Typically, there are four common areas where providers benefit most from additional education:  

Unbundling: Lessen the frequency of individual components being billed separately that are part of a packaged service.

Upcoding: Reduce how often higher severity level codes are billed erroneously when lower-level services are rendered.

Missing support: Decrease the billing of codes where documentation does not support components billed.

Increased compliance: Increase CMS compliance with regulations regarding correct billing and thorough documentation requirements.

Measuring incremental change

After implementing a provider education program, health plans need to accurately measure the incremental change that results. To do this, compare current billing versus the historical baseline for comparable lengths of time. This enables health plans to detect billing trend changes, as well as estimate and track savings driven by education programs.

Continuously measuring behavioral change helps identify providers who may benefit from reeducation. By detecting this need early, you can be proactive in supporting providers so they can accurately bill the first time.

A comprehensive provider education program can help providers master a health plan’s billing process. This leads to meaningful behavioral change that results in:

  • Immediate and long-term cost savings
  • Strengthened provider relationships
  • Increased compliance with CMS correct billing and thorough documentation requirements

Learn more about how your organization can improve billing accuracy with provider education.

  1. Medical Group Management Association
  2. 2021 CMS Comprehensive Error Rate Testing (CERT) Improper Payment Study. <link to:>