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Today, we’re going to discuss a problem that we just ran into recently. It’s not a new problem we’ve seen. It’s something we see frequently. When these kinds of things come up, it’s helpful to remember that everybody runs into them, and we should put out a podcast to discuss it. This one is the rules that are in people’s heads.

We just did a colossal analytics project for a client. We spent a tremendous amount of time on the specifications upfront, where we tried to understand their requirements. We did interviews with managers. We watched demos of their current processes, where they walk through the steps of what they’re doing. 

Manage billing case-by-case

We received access to business files and business rules, where they had documented all of the things that should be done on a case-by-case basis for all these different scenarios in billing. That includes everything from what to do when this type of denial comes back to what we do with this type of charge for this particular payer or these CPT codes when you have this type of diagnosis or any rule you can imagine.

There was a giant table of business rules that were used for the business. We built this large analytics engine to output some answers for them. We do our internal quality control, obviously, to ensure that the system is functioning correctly and outputting according to the specification, and then we give it to the client. There were many different outputs because there are multiple other things that were requested from these datasets. One of the outputs generated several thousand records showing errors in the billing system, where it was not consistent with the clinical system.

Check for inaccuracies

When we gave this to a client, the answer that came back basically was, “They’re supposed to be that way.” And our response was, “No, that can’t be because here’s the specification that you guys gave us that says they’re not supposed to be that way.” Either the specification is wrong, which means the business rules are bad, or the records in the system are inaccurate, but something is wrong. It’s got to be one or the other because they can’t both be correct. So we said, “Which one is wrong?” And the answer that came back was, “Neither.” This time, I was getting frustrated. It can’t be “Neither.” It has to be something. 

Something is wrong because they’re not the same. It’s not matching up. We knew it wasn’t an error in the analysis because it was blatantly obvious. You would look at the records and see they’re different. This wasn’t something complicated. So we tried to figure out, “What’s going on?”

Re-examine your medical billing processes

First of all, this is common. This was a reasonably high-level manager that we were dealing with in the organization. It turns out they weren’t giving us the complete information. They weren’t comfortable telling us what was happening. I don’t want to say they weren’t honest because that’s not the right word. They, I think, didn’t feel comfortable saying, “Hey, something’s broken.”

One of the challenges, and I think what we see often, is that there are tons of little rules that billers and medical billing managers and supervisors have in their heads that they use to be successful to bill successfully and get things paid. It is in all kinds of different departments. It’s everywhere from payment posting to charge entry, to collectors or appeals department or whatever departments you have. 

They all know that there are slight nuances. Anybody who’s been in this business for any time knows that there are little nuances to particular specialties with particular payers or particular medical billing procedures, and you should know how to do this. Otherwise, you’re going to have the wrong output.

Document everything

They may have somewhere in their heads, or somewhere on their computers, or even we still see sometimes sticky notes on people’s monitors or on their desks that say, “Don’t bill X the payer Y. Use Z” or “Don’t use this diagnosis code, or they’re all going to get denied.” The problem is, as an organization, they don’t document distributed information. It’s not centralized, and that creates all kinds of issues.

Final thought

In another podcast, we’ll discuss some issues we run into and how to deal with them.