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Insurance eligibility must be verified before providing services to ensure coverage has not been terminated and benefits have not been exhausted. The medical billing outsourcing market is projected to grow significantly due to challenges in in-house billing processes and the need for compliance with complex coding systems like ICD-10. North America leads in revenue growth, driven by regulatory changes and the consolidation of healthcare practices requiring enhanced revenue management.

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11 views2 pages

industry scale

Insurance eligibility must be verified before providing services to ensure coverage has not been terminated and benefits have not been exhausted. The medical billing outsourcing market is projected to grow significantly due to challenges in in-house billing processes and the need for compliance with complex coding systems like ICD-10. North America leads in revenue growth, driven by regulatory changes and the consolidation of healthcare practices requiring enhanced revenue management.

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client.hyderabad.css01
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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10. Services not covered/coverage terminated.

Because insurance information can change at any time, it’s critical to verify eligibility every time
services are provided. Make sure the patient’s coverage has not been terminated, their maximum
benefit has not been met (for things like physical therapy and behavioural health) and the service
you’re providing is covered by their plan. Understanding the patients plan and the services you
are providing is important. Some plans the services have a cap although if following correct
guidelines and supporting documentation these services will still be covered. Some examples of
these are physical therapy, speech or occupational therapy and the use of correct modifiers.
Coverage can change therefore it is important to verify and receive updated coverage from your
patients. Ask them each time – they will forget to tell you. Again, a proactive approach is
needed. It is also very important to verify before doing procedures and services requiring
precertification under the terms of a member’s plan. If authorization is required then it needs to
be supplied when filing the claim.

CHAPTER-5

INDUSTRY SCALE

The billing outsourcing was valued at USD 6.3 billion in 2015 and is anticipated to reach a
value of USD 16.9billion by 2024, according to a new report Large amount of medical code
representation for diagnosis and treatment coupled with the presence of multiple payers renders
medical billing an intricate part of any medical practice, posing significant challenges. The
challenge mounts when this process mandates adherence to the International Classification of
Diseases-10th revision (ICD-10) code along with dealing with rising healthcare costs and
declining reimbursements. Challenges in managing in-house billing processes include setbacks
experienced in the IT structure, untrained staff, billing errors, and lack of proper financial policy
in place. In order to curb or alleviate these challenges, several healthcare providers, such as acute
care hospitals and clinics/physician offices, prefer outsourcing

According to studies, in 2015, 95% of independent physicians have acknowledged that


outsourcing revenue management is the right decision
Healthcare providers face certain challenges in ascertaining the disadvantages of in-house
operation or benefits of outsourcing revenue management operations; hence, they arrived at this
decision by implementing thorough assessment and evaluation of the revenue percentage they
spend on several billing operations. Currently, the healthcare system is witnessing a subsequent
increase in outsourcing of medical billing services by hospitals and physicians. This increase is
attributed to factors such as obligatory implementation of complex ICD-10 coding system,
increasing healthcare costs, and federal mandate to implement electronic medical records (EMR)
to maintain reimbursement levels.

Furthermore, clinics/physician offices are gradually outsourcing their revenue management to


cut unnecessary costs and prevent the burden of managing an administrative team to ensure
effective handling of in-house billing functions.

Further Key Findings From the Study Suggest:

North America reported highest revenue growth in this market. The U.S. is witnessing rapid
changes in healthcare structure reflected by implementation of new medical coding system
known as the ICD-10 coding as well as pressure from the government to implement EMR
management system. These changing regulations coupled with rising healthcare costs are major
growth drivers for the market in this region.

Multispecialty medical groups are implementing consolidation requiring electronic health record
(EHR) integration and building large healthcare networks This integration creates a need for
Revenue Cycle Management (RCM), which in turn demands additional expertise and trained
personnel to manage the same. Consolidation of large healthcare practices is expected to be a one
of the factors that will help in the growth of the market.

Hospitals end-use segment accounts for the largest market share in the medical billing
outsourcing market. The ability to gain total control over billing procedures and minimize loss is
the m

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