You perform an appendectomy on a patient who comes into the ER with acute appendicitis. It’s a routine procedure you’ve done countless times before. The surgery is smooth, the patient recovers well, and you send them home after a couple nights in the hospital. But then you get a letter from the insurance company saying they won’t pay your full bill because your charges exceed the “reasonable amount” for an appendectomy in your area. Your billing staff did everything right. So why is your reimbursement being denied and questioned? This sort of frustrating situation is exactly why partnering with a medical billing expert can be a lifesaver for doctors like you.

How Can Medical Billing Experts Help Out Doctors?

As a doctor, you rely on receiving accurate insurance reimbursement to keep your practice up and running. Medical billing is complicated, with new codes and rules coming down the pike all the time. Even the most organized billing staff can make occasional mistakes.

Medical billing experts can have your back by:

• Auditing your billed codes against the care you provided to ensure everything matches up properly—this means you get paid fully for all services delivered.
• Catching any duplicate claims or upcoded levels of service that could raise audit red flags. They proactively prevent issues.
• Pinpointing the appropriate “usual and customary” charge ranges for your specialty and area, so you don’t get hit with denials for excessive billing.
• Appealing claim denials and negotiating reasonable settlements if disputes come up with insurance companies. Their know-how really strengthens your position.
• Staying current on the endless coding changes so your bills stay compliant. This avoids penalties and audits down the road.

Why Might Your Medical Bills Get Flagged for Review?

Even if you’re running an ethical practice, there are lots of reasons your medical bills could still attract scrutiny:

• Accidental coding errors since CPT, ICD-10, and E&M codes are incredibly complex. Impossible to master them all.
• Staff mistakes leading to issues like duplicate claims or upcoded service levels. These usually aren’t intentional.
• Your charges exceed benchmarks over time as you raise rates normally. You may not realize the gap has widened.
• Genuine unfamiliarity with the nonstop changes to billing codes and rules—there’s always a learning curve.

You could end up charging more than the accepted reasonable rate for your area and specialty without even knowing it. This can spur audits and problems getting paid properly.

If Your Bill Gets Called “Excessive,” What Should You Do?

If an insurance company won’t pay your full bill because they think your charges are too high, here are systematic steps a medical billing expertcan take to fight it:

• Closely review your billed codes against the medical records. Verify they accurately reflect the services you provided. Appeal anything fishy.
• Check your charges align with the typical range for your specialty and area, based on current benchmarks. Share this data with the insurer.
• If your charges modestly exceed benchmarks, negotiate an acceptable reimbursement amount with solid justification.
• For higher variances, compile data on expenses like malpractice insurance and overhead. Submit this to substantiate going above the norm.
• Leverage medical billing expert’s independent knowledge of fair pricing standards during appeals and talks with the insurer. This lends credibility to your position.

Following this process methodically gives you the best shot at resolving disputes favorably and maintaining your revenue stream.

Why Defining “Usual and Customary” is Tricky Business

A big challenge in settling on appropriate medical fees is confusion around what’s considered “usual and customary” or “reasonable.”

• The American Medical Association says UCR is doctors’ full, non-discounted charges on their standard fee schedules. This sets the ceiling.
• But insurance companies define it as the average amount they actually pay in-network doctors for that service after discounts. This is often way lower than full charges.

With no universally accepted UCR definition, billing experts must rely heavily on benchmarking data to pinpoint acceptable fee ranges based on trends. But experts don’t all have access to the same resources, so UCR standards vary. Navigating this messy landscape takes serious skills. Having billing experts in your corner levels the playing field when insurers claim your prices are “unreasonable.” Their savvy negotiating can help protect your bottom line.

Why Let the Experts Handle Your Medical Billing Disputes

On top of caring for patients and running your practice, you already have a full plate. But billing issues demand quick action before they become financial headaches. Rather than getting sucked into the mind-numbing details, let experienced billing experts take over. They have the coding chops, negotiation tactics, and sheer determination to get your bills paid fairly.

Medical billing experts act as an extension of your team. They’ve got your back when questions come up and know how to respond strategically. With their support, you can stick to delivering great patient care while they protect your practice’s financial wellbeing.