medical billing and coding

5 Provider Coding Myths, Debunked

Over the past 18 months, healthcare providers have grappled with historic cost and care challenges. The COVID-19 pandemic has increasingly forced providers to assess new areas of transformation to unlock operational value and cost efficiencies. Unique trials call for alternative solutions, and health systems are taking a new look at cost and process-challenged areas like coding, which has been an area often operationally underestimated and rife with misconceptions. Here we dispel some common myths by presenting facts about how effective coding can not only help providers survive the current market but start thriving with proactive denials prevention and insights.

1. MYTH: There is no labor shortage..

FACT: There is a labor shortage of skilled coding specialists. Especially in light of the pandemic, businesses across industries are facing critical labor challenges. According to the Bureau of Labor Statistics, since February 2020, as the pandemic took hold in the United States, healthcare employment is down by 542,000 positions. And even before the pandemic, the BLS predicted a surging need for coders, with job growth of 15%. This supply-and-demand scenario is bolstered by the rise of telemedicine, new codes, multiple guideline updates from CMS and AMA with respect to COVID-19 and telemedicine, and a changing service delivery that increases the need for coding expertise. The shortage of workers is driving providers to take a fresh look at business process outsourcers (BPOs), which can provide healthcare coding expertise at a fraction of the cost of onshore workers.

2. MYTH: Offshore coders do not understand US regulations.

FACT: Coding specialists don’t need to be trained in the US. Today’s BPOs can provide well-trained and skilled offshore resources.  HGS, for example, has established a Coding Academy to develop a robust talent pool. The Coding Academy is a world-class coding academy that creates industry ready certified coders who can significantly and immediately add value. Our experienced certified coders are well versed in ICD-10-CM, CPT/HCPCS, National Correct Coding Initiatives, Local Coverage Determinations, National Coverage Determinations and other CMS and payer specific guidelines. Adept at both payer and provider specific coding requirements (diagnostic, procedural and DRG coding), insurance and government regulatory requirements, team members have seeded expertise under SME guidance and cross-trained for related specialties. These team members form the core of a multi-shore capability.

3. MYTH: Outsourcing does not reduce costs.

FACT: The cost of outsourcing is significantly lower than insourcing. BPO coding expertise can represent up to 40-50% discount for first-time outsourcers.domain expertise and clinical specialization to address areas like coding-related denials, which can comprise 30-40% of overall denials. Two-thirds of these denials are not reworked by providers because they do not have time, resources, or skillset to understand and resolve denials. Couple that with an efficient coding and billing process, and a provider can work proactively to prevent nearly 90% of their denials. This lifecycle focus is an area in which coding expertise can deliver, especially those with ecosystem knowledge and multispecialty payer and provider coding delivery. These partners train coding talent from a mindset of dual perspectives—and payer understanding means a more proactive approach for providers with more coding value delivery.

4. MYTH: Coders do not have process expertise or co-create value.

FACT: Coding operations are optimized with innovation and operational excellence. Design thinking, cocreation, and process reengineering are key advantages of BPO, which come equipped with singular process and technology expertise. As innovation hubs that specialize in transformation every day, BPOs can boost coding and clinical expertise with the innovation firepower of automation and analytics skills, domain expertise, and regulatory compliance. For example, solutions such as intelligent analytics enable service vendors to help hospitals stay ahead of the curve to predict potential denials that flag for additional reviews before a claim is sent out to prevent denials. These solutions are supported by customized dashboards to describe top denial reasons, top denied procedures, modifiers, and diagnoses. Finally, with centralization of these coding resources, changes in systems, regular coding updates to stay current and compliant can be implemented quickly and efficiently.

5. MYTH: Coders are not specialized.

FACT: Certified coders are specialized by coding area. Coders gain expertise in specific specialties that are not easily interchangeable. For example, an office coder may not be an expert in coding surgery or anesthesia and vice versa. Similarly, coders are not necessarily experts in resolving denials. Managing a coding denial requires experience and knowledge beyond coding. It is hard for a provider to find a coder meeting their specialty requirement which may result in revenue loss or upcoding resulting in non-compliance against coding regulations. For example, clinical denial-trained coders know how to resolve denials.

The BPOs that can best solve for today’s coding challenges have extensive ecosystem experience working for both providers and payers, giving us a unique exposure to understand both worlds. Our training and best practice sharing are designed to enhance our coders on both teams to prevent denials happening in the first place. By rightshoring the work, our clients can immediately save 40-50%, which goes beyond the cost of labor – finding the right skillset, overhead to work on preventable denials, cost to manage operations, quality, and infrastructure. Through our technology-enabled coding solution, we can reduce coding denials by 50% and will stay you fully compliant with federal regulations.

Lokesh Anbalagan
By Lokesh Anbalagan, Associate Vice President and Head of Medical Coding Practice

Lokesh Anbalagan is the head of HGS’s Medical Coding Practice and has 20 years of experience in the healthcare industry. His role involves development of the solution offering to grow Medical Coding and Payment Integrity in both the Payer and Provider segments.

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