Specialty practice billing is about much more than routine visits and the clinical practice of prescribing. Almost all of the specialists do complex treatments, are more expensive, and operate under more tight guidelines than the primary care doctors.
In our blog, we break down the differences in billing for specialty practices so you can learn how to overcome these unique challenges. We will discuss all you need to know to simplify your practice’s medical billing and coding procedures, from handling complex coding to prior authorizations and high-cost procedures.
Complex Procedures of Medical Billing
One of the most significant problem for specialty practices is the billing for procedures typically involve more complexity than primary care. Error-free coding has to be performed in their special expertise – expansive surgeries, diagnostic tests, and medical procedures.
As an example, a cardiologist performing a percutaneous coronary intervention (PCI), would typically bill for the catheterization, stent placement, and imaging, or components of the procedure. An error in any part of that multi step procedure in the billing can cause either underpayment or rejection by the insurance company. Like an orthopedic surgeon, they might have to take into account things like an old school total knee replacement which is more than just the surgery itself, with the complications that can occur after and the care outside of the operating theatre.
Especially in specialties that often require DME, billing staff must be versed in the specific codes for each procedure; ICD-10 codes for diagnoses and HCPCS codes for anything from supplies to medications.
Specialty-Specific Payers and Insurance Plans
Another complexity specialty practices face when multiple insurance plans are with payers for specific procedures. For instance, oncology practices often treat such high-cost products as chemotherapy and oncology drugs in conjunction with pharmaceutical companies. It means that even prior authorizations, plan coverages, and reimbursement rates for these drugs that are different from the normal HCFA discovery EDIS need to be reviewed by them.
Other specialties, like pediatrics or dermatology, also tend to see a higher level of Medicaid or Medicare patients with their own special set of rules. In addition, Medicare has extremely strict guidelines as to what is covered (and therefore, what is not). There are also lower reimbursement rates for Medicaid.
Besides that, it’s not uncommon to receive clinical documentation requested by payers for certain treatments. Specialty practices must make sure that their documentation accurately records the medical necessity of providing the services. It’s a time-consuming process and makes for another layer of hashing to sort through on top of the billing cycle.
Higher Costs of Procedures and Supplies
In general medicine, medical supplies and treatments are not so expensive, but in specialty practices the costs are usually much higher. For instance, this is particularly true in the fields of orthopedics, cardiology, and oncology, where they have extremely high costs for the particular medical devices (stents, pacemakers, joint implants), as well as the pharmaceuticals (biologics, cancer treatments).
Billing mistakes can be financially devastating with the high cost. For example, losing thousands of dollars on a failure to bill correctly for a pacemaker in a cardiology practice or a biologic in a rheumatology practice. Moreover, coding is the challenge here, and on the spot, making sure that the insurance company will cover the cost. This often requires pre-authorization for expensive drugs and devices.
More Frequent Prior Authorizations
Specialists, by their nature, treat patients with more complicated conditions, and hence prior authorizations are far more common in specialty practices than GPs. It’s essential to get a green light from the insurance company for treatments like biologics, surgeries, or even some diagnostic tests, like MRIs or CT scans.
Unfortunately, prior authorizations can be a real administrative nightmare, often requiring multiple calls, documentation submissions, and follow-ups. But it’s important to have in place a system to manage these authorizations, because not getting them can result in claims that are denied, which may be hard to appeal.
Patient Education on Billing
Typically, patients in specialty practices have higher out-of-pocket expenses compared with those at primary care practices. For high-cost treatments, complex procedures, or medications that your insurance doesn’t cover 100%, you as a specialty practice will have to spend time educating patients regarding billing and insurance coverage.
Doctors and associated billing staff need to communicate clearly the cost of treatments, the patient’s share of that cost, and how insurance may apply. Especially in areas like oncology or fertility medicine, where costs can run into the tens of thousands of dollars, misunderstandings about coverage do not only result in frustration; they can lead to financial hardship for patients.
Further, insurance navigation should be provided at practices by endorsing a verification service before a patient goes through a costly process. That can help avoid surprises when the bill comes.
Managing Denials and Appeals
As procedures are more complicated, specialty practices usually have higher denial rates than general practices. This can be for pretty much any reason, from incorrect coding to not enough documentation to lack prior authorization to payer-specific policies not being followed. That’s why it’s so critical to have a process in place for handling and appealing denied claims.
Denials, therefore, have to be tracked, known why they happened, and resolved quickly in specialty practices. In some cases, you have to appeal the denial with additional documentation or coding corrections.
Investing in Specialized Billing Staff and Technology
Finally, specialty practices stand to benefit greatly from investing in trained billing staff that can distill the complexities of the specialty field. Specialty medical billing can be complicated, and not having general billing knowledge isn’t always enough.
Besides having the staff trained, they also need to factor information from specialty-specific billing software. There are many software platforms designed to work with specialized things and include inbuilt templates and code suggestions to cut short any errors and time billing. For instance, some platforms provide cardiology-specific tools that include ECG results for claim submission faster.
The right technology at hand will reduce the number of errors, speed up payments, and contribute to the revenue of the practice.
Conclusion
Specialty practice medical billing is more complex and more detailed than general practice billing. Specialists face higher costs of procedures, frequent prior authorization, complex coding requirements, and payer-specific requirements. While it’s possible to get paid for the services you offer specialty practices provide, with the right technology and processes and good help, it’s possible to make sure you’re being paid the right amount for what you are doing.
Knowing these differences and putting the necessary resources in the right place could significantly change your practice’s financial health.
