In the realm of fertility clinic billing, a wide range of treatments and procedures – all closely related to human reproduction – qualify for reimbursement under the patient’s health plan. Each of these can further contain multiple components around fertility consultation, diagnostic services, fertility treatments, medications, and possible surgical interventions.
Billing for additional services for fertility patients adds extra layers of complexity and variability associated with these forms of treatment, which may differ based on each patient’s individual circumstances, and have multiple phases which happen over time. Billing by a fertility clinic typically involves aspects such as insurance verification, estimating out-of-pocket costs, preparing and submitting claims, offering multiple payment plans, and other related parts of the revenue-generation process.
Because of the coverage often being less than what patients anticipate, it is important for the clinic to disclose upfront to the patient about costs, what services are covered by insurance, what could be out-of-pocket or copay amount, and then discuss available financing options. It is important for the clinic to have accurate charges so that it operates smoothly and efficiently. It is equally important to have proper coding and documentation to help resolve any issue that could likely arise, such as claims being denied or taking too long to be processed.
More broadly, effective billing practices within a fertility clinic protects the economic viability of the practice, while protecting the patients’ emotional and fiscal interests through what can be considered candid conversations regarding fertility and fertility treatment solutions, not forgetting that these conversations are often complex and more emotionally charged financial discussions than usual.
Most notably, fertility clinic billing has the complication of determining the actual insurance coverage. Unlike other health coverage services, and with a patient’s own insurance plan and employer benefits involved, fertility treatments can have unique individual coverage limits or no coverage base. It means billing departments must have a thorough understanding of payer coverage, coverage limitations, and pre-approval requirements based on the specific rules established by each payer.
Additionally, billing of fertility services requires a clear understanding of medical coding that is inseparably tied up with payer reimbursements. There are three chief coding systems, each demanding the highest level of accuracy. These comprise ICD codes, CPT codes, HCPCS codes and potential modifiers for each code. Each code needs to have clinical documentation to support medical necessity and limit the risk for denials and audits. Ultimately, fertility billing that works well means timely reimbursements and a better patient experience with less chance for confusion or delays regarding financials.
Successful fertility billing, in the final analysis, means timely reimbursement and a better experience for the patient with less financial confusion and fewer delays. Many clinics choose to use dedicated billing teams or outsource billing to experts in reproductive health billing to allow for a focus on revenue optimization and patient satisfaction.
Key Challenges in Fertility Billing Services
1) Various Insurance Coverage
Fertility services are usually covered by distinct insurance policies. Tracking different coverage particulars and determining patient eligibility can be cumbersome and difficult.
2) Codes That Are Not Straightforward
Fertility billing uses multiple specialty codes. Each procedure has its own code. If the coding in not accurate, it often leads to claims denial more often.
3) Claims Denied on an Ongoing Basis
Claims for fertility services are often denied due to mistakes while drafting the claim, omissions of requisite data, or missing the filing deadline. Various factors related to documentation or pre-authorization may also limit payment. All these denials require time-sensitive adjustments and appeals.
Strategies to Consider for Improving Fertility Billing
1) Accurate Patient Data Collection
Getting accurate data is the first step in successful billing practice. Having proper demographic, insurance, medical, and treatment history items, which are all captured and verified, prevents claims issues for delays and denials. The staff should be trained in both data entry and verification.
2)Reducing Coding Errors
Coding mistakes can result in delays or denials because of enacting an outdated code, using a code that does not match the procedure, or matching the wrong procedure. To reduce coding errors, practices should order certified medical coders, invest time in coding training, embed their coding checks in their billing system, or add coding validation within their electronic medical record (EHR) systems. A practice or coding organization should audit regularly, which includes capture and coding of details, so any mistakes could be fixed prior to any claim submission.
3) Make Denied or Rejected Claims a Priority
Develop an efficient process in dealing with the claim reconsideration as timely as possible. Account for time-keeping driven amounts from appeals and piece together documentation without excessive formatting. It is important to be able to evaluate trends to avoid making the same mistakes.
4) Monitor Your Revenue Cycle Performance
Observing how efficiently your fertility center is managing its billing process can reveal opportunities for evolution. You should always be aware of your fertility billing process’s key performance indicators (KPI), namely: days in accounts receivable (AR), first-pass resolution rate, denial rate, and net collection rate. Billing analytics software will assist that will help improve decision-making and ultimately enhance overall productivity.
The Value of a Specialty Medical Billing Company
Given the complexities involved in fertility center billing, a specialty medical billing company may put forward a workforce with relevant experience and higher success rates.
1) Better Fertility Billing Experience
A company specializing in fertility services is more likely to have the expertise of experienced people involved with the process and the differences in fertility treatment. Their expertise can help reduce human errors relating to insurance policy exclusions and understand eligibility requirements to make the billing process more streamlined.
2) Time Efficient Pre-Authorization and Claim Management
A full-service billing company can help submit billing requests in a timely manner while ensuring no one forgets to submit a claim. Their knowledge of the available insurance vendors and requirements provide confidence with coverage, pre-authorizations, claims management, and maximum reimbursement for the fertility center.
3) Appeal Expertise
Fertility billing has one of the highest denial rates in medical billing. A specialized medical billing company will be versed in the appeals process and laws and regulations that govern the appeal. They will resubmit denied claims with the required documentation and can improve the chances of the claim being covered by insurance.
4) Transparent Financial Counseling
The billing company has the option to offer financial counseling to the patients, which will include transparent and simple explanations of what is covered and what the patient’s potential out-of-pocket costs will be. This really reduces the chance of an error in billing, and makes the patient’s experience better when they are ready to pay for the service.
5) Less administrative burden
The number one priority of fertility centers is patient care, but administrative duties like billing can take away from that goal. Working with a dedicated medical billing company can allow fertility centers to focus on the care provided while we work through complex billing issues.
Fertility billing is very specialized. A dedicated fertility billing company can create a streamlined process to ease the burden of billing, improve the rate of reimbursement, and allow fertility clinics to provide patients with excellent patient care.
The right billing partner can transform the revenue cycle. They reduce denials and maximize collections. In today’s healthcare world, partnering with an outsourcing firm could keep your practice profitable and patient-focused. Through outsourcing, providers can lower costs by as much as 80%, with hourly rates starting at $7. Vendors offer services tailored to their specialties as well as full end-to-end revenue cycle management.