As a healthcare provider, your focus is on patient care—not navigating the complexities of medical billing and collections. Unfortunately, misconceptions about billing and collections can lead to lost revenue, legal trouble, and compliance risks. Healthy revenue cycle management is the difference between a practice that survives and a practice that thrives. Below are five common myths and the truth behind them. 

1.Patients Don’t Care About What Their Insurance Gets Billed 

This is far from the truth.  With the rising costs of health insurance and out of pocket expenses, patients are very much interested in what they see on their bill and expect clear communication about what they or their insurance is being charged.  Mistakes happen, but that’s rarely how it’s seen.  A dissatisfied or unhappy patient is more likely to make inquiries directly with their health plan about their bills, which in turn could result in an audit of the physician’s practice. 

2. If My Group Does the Billing, It’s Not My Responsibility 

The Department of Health and Human Services and Centers for Medicare and Medicaid Services expect physicians and coders to work jointly “to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.”  Larger physician groups often take advantage of that joint relationship by outsourcing billing and require strict billing compliance sometimes under short time constraints on the physician.  Busy providers often feel they don’t have the time to review all the bills or the coder’s suggested changes while also keeping up with their patient needs. However, the provider is ultimately responsible for what gets billed when it’s time for an audit or a lawsuit.  If there are systemic disagreements, contact a lawyer. 

3. Billing and Collections is Automatic and Claim Denials are Inevitable 

The billing and collections process can be very time consuming and require a substantial amount of human resources.  The process often requires follow up with health plans or government payers, filing appeals, and making sure the plan or payer has not wrongfully denied a code or wrongfully bundled or down coded a service.  The process also requires the coder being up to date with the constant changes in coding and billing procedures as well as changes in the law.  Non-contracted providers can be defaulted to rates far below what they may otherwise be entitled to based on their experience, training, and geographic location.  With properly negotiated contracts, the expense of outsourcing billing and collections can be offset by additional practice revenue and freeing up staff time that can be spent on patient services. 

4. I’m stuck with the CPT Codes the Health Plan Will Pay 

This isn’t always the case.  CPT codes were created by doctors for doctors.  The point of the CPT codes was to have a way to standardize the payment process to streamline the delivery of healthcare.  In other words, the medical services are supposed to drive the CPT, not the other way around.  With the fast-paced innovation of today’s health care space, the CPT codes lag behind the value being provided to patients.  Healthcare providers, including specialists, implementing a new technique or technology can appeal to the plan for a code that applies to the service their providing. 

5. It is Impossible to Challenge a Recoupment Demand 

It can be overwhelming to receive a demand from a health plan or payer months or even a year after you cashed the reimbursement checks demanding that they’ve overpaid you and wanting some or all of the money back.  In California, you may not always have to pay that money back.  There are specific notice and timing requirements a health plan has to comply with before a demand can be enforced.  If the services relate to ERISA plans, then additional notice requirements could be triggered.  Ignoring a recoupment demand though is a sure way to find yourself in a collection action, flagged as high risk by a health plan, or worse.  An experienced health care lawyer can help you navigate this process. 

Conclusion 

Navigating healthcare billing and collections requires not only financial diligence but also legal awareness. Providers should stay informed about the latest regulatory changes and ensure that their billing policies align with federal and state laws. Consulting with a healthcare attorney can help mitigate risks and ensure compliance.