New Analysis Shows Preventive Care Claims Systematically Underpaid Due to Incorrect Code Combinations
Los Angeles, CA — A comprehensive analysis of 40,000+ preventive care claims from family medicine practices across the country reveals a troubling pattern: Practices are not capturing an average of 22% of their preventive care revenue because of bundling mistakes. The error is so prevalent that you’d never notice it except for the numbers.
The issue is a technical one, but it’s costing family practices real dollars. Practices may be correctly billing preventive codes when the patient presents for an annual visit. However, evaluation codes, minor problem-focused evaluations or counseling services are being added in a manner that activates bundling rules. The combinations of codes that should not occur together come up before the payers, the add-on is denied, and in a blink of an eye, a $250 visit becomes $195
“Family practices are running lean,” says one billing director from a 12-provider practice in Texas. “When you’re seeing 30 patients a day, sometimes the billing details slip. But when 22% of your preventive revenue evaporates to bundling denials, you notice pretty fast. That’s money that should be paying staff salaries.”
Three bundling scenarios were identified by the DoctorMGT analysis that result in virtually 80% of the claim reductions for preventive visits:
Prevention + Problem Visit Stacking (44% of losses):
Practices bill preventive codes alongside established patient problem codes for the same visit when payers expect a single combined code instead. Result: Automatic bundling denial.
Preventive Counseling Overrides (28% of losses):
Standalone preventive medicine or counseling codes, when added to a preventive visit, will start a “bundling” rule that will be interpreted as a duplicate claim on the part of insurers.
Screening/Risk Factor Code Combinations (18% of losses):
Billing out preventive screening codes and chronic disease management codes together is confusing because payers will bundle the lower-paid code together with the higher-paid code.
That 22% loss represents nearly $15,000 in unearned income per month for a 10-provider family practice that provides 300 preventative visits each month at $225 average reimbursement. This is $180,000 in revenue that practices should be getting in preventive care visits each year.
The thing is, this is avoidable. There are valid reasons for bundling rules, namely, that payers do not wish to pay more than once for the same service. However, family practices must have documentation requirements and billing practices that meet the expectations of payers. It’s not fraud, it’s the practices losing the most money. Not purposefully stacking codes. Their workflows are outdated or they are missing parts of the payer rules that change from year to year.
There are three key steps to the solution: audit your billing patterns for preventive visits. Your specific payer fee schedules, educate your staff on the specific rules and regulations behind the billing codes for family medicine preventive visits. Put a pre-submission review process in place to reduce the risk of billing conflicts that happen before claims leave your office.
If practices are prepared to make up those lost profits for prevention. There are detail best practices guidelines, as well as state-specific bundling rules.
Contact:
DMS Press, Media Relations
201 E Center St Suite 112, Anaheim,
CA 92805, United States
Tel: (+1) 657-999-7255
Email: info@doctormgt.com
Website: www.doctormgt.com