The Major Challenges Healthcare Facilities Face in Billing and Receiving Treatment

Medical billing is considered the backbone of the healthcare revenue cycle. It keeps institutions profitable and ensures healthcare practitioners are paid. It is also key to the survival of any laboratory or practice. In hindsight, an effective medical billing process is what sustains a healthcare facility to deliver quality care to patients. 

While most medical practices understand the need to bill and collect money from patients efficiently, medical billing has many challenges. Constant changes in government regulations concerning patient care and payments, as well as advancements in technology enables constant changes in medical billing processes. It forces institutions to adapt and adjust while also trying to manage patients all at the same time. But to deliver the best care to patients, it is imperative to identify and address this issue effectively. Here are the major challenges medical billing and receipt of payment faced by healthcare facilities in recent times.

Missing and Incorrect Patient Information

In 2022, over 33 million patients were admitted across U.S. hospitals, which means institutions collected and coded millions of data as well. Not all institutions have the advanced technology and tools to record everything correctly or make sure everything is accurate. Many healthcare institutions, especially community hospitals, still manually manage patient information. This causes human errors and can lead to losing patient information. Thus, when billing and payment settlement comes, it becomes difficult to trace who received what treatment when. This causes confusion between the institution, the patients and financial institutions, like insurance providers. 

Insurance companies can easily deny a claim because of missing or incorrect information. Errors as simple as a blank field or spelling mistakes can lead to claims denial. 

Therefore, billing and coding staff have to be well-trained and must work together and double-check every entry for accuracy. Healthcare institutions can work with medical billing and coding organizations to make sure they will have professional staff trained to record patient information correctly. It is also ideal to leverage tools and technology to record patient information fast, store it systematically, and ensure traceability for faster claims and payment processing. 

Missing Documentation

Getting treatment and paying it off through financial service providers requires a lot of paperwork. Missing documentation has become one of the most common causes of delay during billing. Every insurance company requires precise documentation to pay certain claims and they will not hesitate to decline any claim with just the lack of a single document they need. Rejected claims means the hospital will not get paid even if they have rendered service to patients. 

Most hospitals with legacy systems and traditional filing cabinets face a significant challenge when it comes to keeping and retrieving documents when needed. It is important to consider this and invest in improving records and documentation processing. Integrating software solutions and migrating physical documents into digital formats can help healthcare institutions better manage patient records. It will allow for more systematic storage and faster retrieval, which will also aid in processing payments and claims more efficiently.  

Missing Referral or Authorization

In some instances, patients must get a referral from their primary care physicians before accessing certain healthcare services. This often applies if patients need to get treatment from a specialist or have a more complex case that needs advanced treatments. 

Referrals are also considered during the billing process. But because of the blurry and confusing process, the referral system has been seen negatively in the healthcare sector. More often than not, referrals and authorizations are difficult to track, and the lack of which can result in claim denial.

Having a proper referral management in place can help hospitals manage referrals and authorizations better. There are various software solutions available for referral management which can help clinics, specialists, and their patients to have a smoother and more seamless process. Patients can get the right treatment right away, while health facilities can manage billing and make claims faster. 

Services Not Covered

Health insurance coverages can be tricky and most of them provide very limited financial protection. Sometimes, patients are not aware the service they needed is no longer covered by their insurance until it is time for payment. This often happens when the patient changes employment or health insurance provider, or they failed to make payments for their insurance. 

In 2021, nearly 299 million Americans had health insurance, but a survey suggests that 43 percent were inadequately insured. This means their insurance is insufficient and cannot cover full payments for healthcare services they get. They have to make out-of-pocket expenses amounting to at least 10% of their household’s income.

This causes inconvenience for the patients, being taken by surprise. At the same time, this poses a risk for hospitals to not get paid for the service they provide. This instance can be inevitable, especially during emergencies and when patients need urgent care. However, employing proactive steps to check insurance coverages and properly informing patients about how insurance works can help minimize this hassle. 

Lack of Patient Education

Relative to not knowing how their insurance works, many patients lack education on how billing, payments and claims work when getting healthcare services. Some patients may have no idea that the service they are trying to access requires referral or authorization or that their insurance coverage has changed for some reason. This often causes a lot of confusion and back-and-forths between the healthcare institutions, patients and insurance providers.  

This dilemma requires a collective effort from all stakeholders — healthcare institutions, insurance providers, government and the patients as well. Everyone has to work collaboratively to spread information and make sure that everyone is up-to-date when it comes to dealing with healthcare services. Information drives and ads, as well as other active marketing efforts can help clinics and hospitals better inform their patients even before they need to go to a hospital to get treatment. 

Improving the Billing Process to Deliver Better Care 

Billing and payment processing seems like a whole different realm within healthcare institutions. But in reality, it is just a part of the whole system that needs to work holistically to provide the care patients need. For healthcare facilities to deliver patient care and innovate treatments, sufficient funding is needed. Institutions need to generate revenue to further invest in their workforce, facilities and tools, to address evolving health problems.   

Leverage technology and develop timely approaches to address challenges in information management. This eases the burden of processing documents and making claims. It also ensures patients have access to their data as needed. Moreover, hospitals need to take part in informing patients and assisting them to better understand insurance coverage and billing processes, and avoid confusion and delays both in making payments and receiving treatments.