We wouldn't, yet U.S. health care providers do that every year because 80% of medical bills sent out contain errors. Why? Because doctors, medical coders, and billers are human. Humans make mistakes. They also need to comply with an ever-growing complex set of rules and medical codes.
Yes, medical codes.
There are nearly 100,000 ICD-10 (International Classification of Diseases, 10th Revision), diagnostic and procedural codes an insurance company needs in order to pay a health care provider. Medical coders need to pick the right codes, but they're human also and make mistakes.
Did you go to an urgent care for a simple ear infection? Well, it's not so simple.
There are 80 diagnosis codes associated with every type of middle ear infection, its cause, location, complications, whether it's acute or chronic, etc. In addition, there may be procedures performed and your visit must be placed - correctly - within 5 levels based on the severity of your condition. YES, it's complicated.
If a coder incorrectly translates the doctor's diagnosis, procedures, or level of visit ("Visit Code"), the doctor does NOT get paid.
Even the smallest coding error will cause the insurance companies to reject the claim. This starts a lengthy process of requiring the doctor to fix the error, submit a second claim, and then wait several months or more, hoping the new claim will be accepted and paid.
Coding Errors For A Typical Urgent Care
Wait, there's even more coding issues: Up-coding & Down-coding
Up-coding is reporting incorrect codes that result in a higher payment by the insurance company while patients are billed for more complicated conditions they didn't have or procedures they didn't receive. This can be considered fraud and lead to prosecution, with legal and high financial penalties.
The opposite issue down-coding, is not including proper codes for all diagnoses addressed and procedures performed or coding them incorrectly for diagnoses and procedures that are reimbursed at a lower rate. This results in lost revenue for the provider.
Aside from lost revenue, if medical records are coded incorrectly, patients' health data will be corrupt, directly contributing to the quality of patient care, and putting their health at risk.
Incorrect codes also negatively impact population health management and chronic care management that directly rely on quality health data to predict and prevent diseases.
Unfortunately, in today's world, one of the biggest challenges facing doctors today is not solely focusing on patient care.
Rather, today's care providers are concerned with the business side of health care and the sustainability of a medical practice especially relating to medical billing and coding.
The healthcare industry is recognizing these issues within the $30 billion "Revenue Cycle Management" market which tracks revenue from the first doctor's visit to payment.
By 2022, annual spending on Artificial Intelligence related tools will exceed $8 billion.
Elip Solutions witnessed these ever-growing issues years ago and committed ourselves to develop a better way - both for health care providers and patients. We then spent years and devoted resources building our automated platform, Elip Coder.