How Automated Insurance Verification is Reshaping Healthcare Revenue in 2025
Healthcare organizations incur losses amounting to millions annually due to a single administrative bottleneck that many could resolve. Each phone call made by your staff to confirm insurance coverage squanders valuable resources, consuming 25-30% of front desk time and introducing human errors that lead to expensive claim denials. The answer lies in automated insurance verification systems, which eliminate manual tasks and provide real-time eligibility information with unmatched precision. These platforms seamlessly integrate with electronic health records, connect directly to insurance databases, and verify coverage in seconds rather than minutes. This guide outlines how automated insurance eligibility verification can decrease claim denials by as much as 40%, save 3-5 hours each day for every staff member, and avert millions in revenue losses while enhancing patient satisfaction and operational efficiency. What is Automated Insurance Verification Automated insurance verification represents a significant departure from the traditional manual verification processes that have burdened healthcare providers for many years. This technology employs specialized software to electronically verify patient insurance eligibility, substituting labor-intensive phone calls and fax communications with immediate digital connectivity. The essential elements of these systems include real-time database connectivity with payer systems, smooth integration with current electronic health records, and batch processing capabilities that allow for the verification of hundreds of patients simultaneously during off-peak hours. In contrast to manual methods that require 5-7 minutes per patient verification with error rates of 15-20%, automated solutions yield results in 2-3 seconds with accuracy rates exceeding 99.5%. The market for insurance verification software is expanding rapidly, with projections indicating it will reach $11.4 billion by 2027. This expansion is attributed to the necessity for healthcare providers to digitize their administrative operations and adhere to evolving healthcare regulations while navigating intricate payer environments. Contemporary verification software interfaces directly with major insurance companies via secure APIs, obtaining real-time eligibility information from Aetna, Cigna, UnitedHealthcare, Medicare, and Medicaid systems. These systems are capable of verifying over 500 patients during off-peak hours and securing complete coverage validation prior to the commencement of business hours. The Burden of Manual Insurance Verification The process of manual verification imposes a significant administrative load that extends beyond mere time consumption. Front desk personnel dedicate 25-30% of their daily activities to verification-related phone calls, creating bottlenecks that hinder patient flow and satisfaction. Each manual verification attempt consumes 5-7 minutes per patient, during which staff must navigate complicated phone systems, endure hold times, and manually record insurance details that are susceptible to human error. The financial repercussions are even more severe. The rate of human error in manual data entry ranges from 15-20%, leading to inaccuracies in patient records and insurance details. These inaccuracies are directly responsible for 8-12% of all claim denials, prolonging payment cycles by 45-60 days as claims must be resubmitted and rectified. Financial Consequences for Healthcare Organizations Large healthcare institutions bear the brunt of these issues, with eligibility-related claim denials threatening an annual revenue loss of $3-5 million. Smaller practices are not exempt; they face a 15-25% decrease in cash flow due to inefficiencies in verification processes and administrative expenses that accumulate to $12-18 for each patient encounter. The cascading effects persist, with staff overtime costs rising by 20-30% as teams endeavor to manage verification backlogs and reprocess denied claims. Manual verification generates operational bottlenecks that hinder staff from concentrating on higher-value tasks that have a direct influence on patient care and satisfaction. Administrative expenses accumulate when one considers the entire range of manual processes. In addition to labor costs, organizations must factor in communication expenses, documentation overhead, and the opportunity cost associated with delayed patient services. Numerous healthcare organizations discover that their administrative bottlenecks adversely affect their financial performance and hinder their ability to enhance cash flow. How Automated Verification Functions Automated verification platforms operate via real-time database connectivity, accessing insurer systems within 2-3 seconds and providing instant eligibility confirmation through secure API integration. These systems connect with over 1,000 payers, including Aetna, Cigna, UnitedHealth, and government programs, ensuring comprehensive coverage validation across various insurance landscapes. The technology facilitates batch processing of more than 500 patients simultaneously during off-peak hours. This method guarantees that patient verification occurs prior to appointments, minimizes disruptions during busy clinical hours, and optimizes system efficiency. Sophisticated platforms offer automated alerts and notifications regarding coverage changes, pre-authorizations, and policy expiration dates. These proactive features assist healthcare providers in staying ahead of billing challenges and ensuring that patient insurance information remains up-to-date throughout the care relationship. Pre-Service Verification Procedure The most advanced automated systems arrange verification checks 24-48 hours before patient appointments, identifying potential coverage issues before patients arrive. This pre-service strategy enables staff to address issues proactively, thereby reducing appointment delays and enhancing the patient experience. During the pre-service verification process, systems evaluate coverage details, including copays, deductibles, and benefit limitations, before service delivery. This thorough analysis allows staff to provide patients with accurate out-of-pocket costs, improving transparency and minimizing billing surprises that could affect patient satisfaction. Insurance discovery features represent a crucial capability, enabling the identification of additional coverage from external databases for patients who initially appear as self-pay accounts. Since one in six Medicare and Medicaid patients undergo coverage changes monthly, it is vital to engage in continuous monitoring to uphold accurate eligibility data and minimize claim denials. Key Benefits of Automated Insurance Verification The shift from manual processes to Automated Insurance Verification (AIV) yields significant enhancements across various operational domains. The most immediate advantage is the reduction of errors, with automated systems achieving accuracy rates of 99.5%, in contrast to the 80-85% accuracy of manual verification methods. This enhancement in data quality results in fewer claim rejections and a more streamlined revenue cycle. Another substantial benefit is the time savings, as automated systems can decrease verification time by 4-6 minutes for each patient encounter. This increase in efficiency enables administrative personnel to concentrate on patient care activities and other high-value tasks that enhance overall practice operations and patient satisfaction. Financial protection stands out as perhaps the most significant advantage, with automated verification
Frequent HCPCS Coding Errors in Radiology Billing and Strategies to Prevent Them
Radiology practices frequently neglect to apply separate charges for essential items, including imaging supplies, contrast dye, and radioactive tracers, as their attention is primarily directed towards the main scans and diagnoses. When personnel fail to bill for these expensive materials, practices experience revenue loss and face the risk of compliance violations. A single mistake in billing for a radioactive tracer can result in costs exceeding $1,000 per study. With Medicare reimbursement rates projected to decrease by approximately 2.9% in 2025, these HCPCS challenges are increasingly significant for radiology professionals. This guide outlines prevalent HCPCS challenges and effective strategies to address them. Why is HCPCS Essential in Radiology Billing? CPT codes document the procedures performed, such as MRI scans, CT studies, or PET scans. In contrast, HCPCS codes account for the materials utilized, such as the $2,000 PET tracer, the $300 gadolinium injection, or specialized catheters. Failing to include these supply codes results in the expensive materials being treated as practice overhead rather than being compensated for. This issue is a common occurrence in radiology. Practices tend to concentrate on the high-cost imaging procedures while disregarding the costly materials that enable those procedures to be performed. The most frequent areas where practices incur revenue losses include: Contrast Agents Each type of contrast requires specific HCPCS codes that depend on its composition and delivery method. Gadolinium-based MRI contrast necessitates different codes compared to iodinated CT contrast. Utilizing generic codes instead of the specific agent codes leads to systematic underpayments. Radiopharmaceuticals PET imaging depends on costly tracers that come with intricate billing regulations. Some codes charge per study dose, irrespective of the millicuries used, while others charge per millicurie administered. This differentiation influences whether you bill for one unit or fifteen units for the same injection. Interventional Supplies Catheters, guidewires, and specialized devices employed during interventional procedures are often eligible for separate billing. Omitting these charges can convert profitable procedures into scenarios where the practice breaks even or incurs losses. Frequent HCPCS Coding Errors in Radiology Billing The following outlines the most common HCPCS errors encountered in radiology billing, along with their respective solutions. Incorrect Units for Radiopharmaceutical Billing Radiopharmaceutical codes adhere to distinct billing regulations that many practices misinterpret, resulting in considerable revenue loss. The Issue Certain codes bill “per study dose, while others bill “per millicurie. Code A9503 encompasses up to 30 millicuries but bills as a single unit, irrespective of the actual quantity utilized. Numerous practices mistakenly bill 15 units when administering 15 millicuries. The Resolution Educate staff to distinguish between “per study dose” and “per millicurie” descriptors. Develop quick reference cards that outline unit rules for frequently used radiopharmaceuticals. Insufficient Documentation for High-Cost Tracers Unlisted tracer codes necessitate comprehensive documentation that many practices neglect, leading to claim denials. The Issue Codes such as A9598 require documentation of the product name, NDC number, dosage, and invoice cost. The absence of any of these elements results in denials. Random audits demand invoice verification, and incomplete records necessitate the repayment of received funds. The Resolution Establish documentation templates for unlisted codes. Mandate the inclusion of invoice copies and complete product information before billing any NOC radiopharmaceutical codes. Billing for Contrast When It Is Already Included Payer bundling regulations differ significantly, confusing regarding when contrast can be billed separately. The Issue Certain payers bundle MRI contrast into procedure payments. Billing it separately breaches contracts and initiates compliance reviews. Each payer has varying bundling rules that are subject to change quarterly. The Resolution Keep up-to-date bundling reference guides for major payers. Review payer updates every quarter and modify billing protocols accordingly for each contract. Insufficient Contrast Documentation Details Inadequate contrast documentation hinders accurate HCPCS coding and leads to systematic revenue loss. The Issue The type and quantity of contrast must be recorded in the technique section prior to the addition of supply codes. Incomplete information regarding specific contrast agents, volumes given, or methods of delivery hinders precise HCPCS code selection and reimbursement. The Resolution Mandate that technologists record the precise type of contrast, volume, and method of administration. Develop standardized templates for documenting contrast in imaging reports. Prior Authorization Shortcomings for High-Cost Agents High-priced radiopharmaceuticals and contrast agents frequently necessitate prior authorization, which practices often neglect to secure. The Issue Advanced PET tracers, which cost between $3,000 and $5,000, require pre-approval before administration. The absence of authorization results in automatic denials, irrespective of medical necessity. Emergency studies exacerbate this issue when time constraints prevent authorization requests. The Resolution Establish pre-authorization tracking systems for high-cost agents. Confirm coverage before scheduling and maintain databases for authorizations with tracking for expiration. Billing System Mapping Mistakes Chargemaster systems frequently misclassify procedures under incorrect HCPCS codes, leading to systematic billing inaccuracies. The Issue Technical personnel document bilateral imaging on charge tickets, yet billing systems assign unilateral procedure codes. Therapeutic infusions are incorrectly categorized under hydration codes. These mapping inaccuracies result in consistent underbilling across numerous claims. The Resolution Perform quarterly audits of the chargemaster with both clinical and billing personnel. Cross-verify charge ticket descriptions against the actual HCPCS codes in your billing system. When discrepancies are identified, promptly update mappings and utilize test claims to validate corrections before implementation. Volume Calculation Errors Inaccurate dosage calculations result in incorrect unit billing and substantial revenue discrepancies. The Issue Per-milliliter codes necessitate accurate volume calculations. Billing practices that charge per vial rather than the actual milliliters administered overlook potential revenue. Additionally, the requirements for waste documentation further complicate the precise determination of units for costly agents. The Resolution Educate staff on the differences between per-unit and per-volume billing. Establish protocols for verifying dose calculations. Ensure proper documentation of waste for high-cost radiopharmaceuticals. Incomplete Invoice Records for Audits The absence of invoice documentation poses a risk during payer audits and
Leveraging Advanced Analytics to Drive Value-Based Healthcare Systems
Healthcare systems worldwide have experienced a transition from the conventional fee-for-service model to a more patient-focused approach aimed at enhancing patient healthcare outcomes, exemplified by the Value-Based Healthcare (VBHC) model. This model, driven by patient outcomes, seeks to emphasize the quality of healthcare, as payers reimburse providers based on the value and results of the care delivered. Payers set quality standards and objectives that providers must achieve to qualify for full reimbursement; failure to meet these standards can lead to significant penalties. In this blog, we will examine the significance of advanced analytics within a value-based healthcare framework and how it contributes to improved patient outcomes alongside cost management strategies. Additionally, we will review the challenges and advantages of integrating advanced analytics into healthcare delivery, supported by real-world examples demonstrating their positive impact. What is Value-Based Analytics? Value-based analytics involves the application of advanced technologies, including machine learning, artificial intelligence (AI), and data mining, to evaluate and manage risks. By scrutinizing extensive datasets, these technologies yield actionable insights that enhance healthcare delivery, optimize patient outcomes, and ensure quality and affordability. In contrast to traditional data analysis, which typically emphasizes descriptive statistics and historical data, advanced analytics employ sophisticated algorithmic techniques to forecast future events and outcomes, provide problem-solving recommendations, and identify patterns that may not be immediately apparent. In the field of healthcare, advanced analytics entails the examination of extensive patient data (including clinical, demographic, behavioral, etc.) through the following methods: Predictive Analytics: This involves identifying patients who may be at risk of developing chronic conditions or facing readmission to the hospital. Prescriptive Analytics: This method recommends specific interventions or care plans tailored to patient health data and characteristics. Descriptive Analytics: This involves the analysis and reporting of key performance indicators (KPIs) to yield insights into patient care outcomes and related costs. How Advanced Analytics Enhances Value-Based Healthcare • Enhancing Patient Health Outcomes Advanced analytics models have the potential to significantly enhance patient outcomes by forecasting health risks, pinpointing possible complications, and striving to avert future issues. For instance, predictive models can detect patients at high risk for chronic conditions, readmissions, or adverse events based on historical data. Consequently, healthcare providers can implement earlier interventions through personalized care plans to mitigate these adverse outcomes, thereby improving overall health and quality of life. Moreover, analytics tools can continuously monitor patients, notifying clinicians of any changes in a patient’s condition. This data-driven methodology facilitates timely modifications to care plans, ensuring that patients receive the most suitable care at the appropriate time. • Optimizing Healthcare Expenses: A primary objective of value-based healthcare is to lower the overall cost of care while preserving or enhancing outcomes. Advanced analytics aids in cost management by uncovering inefficiencies, such as unnecessary tests or clinical procedures, and assisting healthcare organizations in optimizing their revenue cycle. Predictive analytics can foresee patient requirements and avert hospital readmissions, which can impose a considerable financial strain on both patients and healthcare systems. By examining trends in patient behavior and treatment results, value-based analytics tools can pinpoint the most effective and cost-efficient models, thereby assisting providers in delivering superior care at reduced costs. • Customized Care Plans: Each patient possesses unique characteristics, and what may be effective for one individual might not be suitable for another. Advanced analytics empowers healthcare providers to tailor treatment plans according to individual patient data and medical history. By integrating clinical data with demographic and lifestyle information, prescriptive analytics tools can aid clinicians in formulating personalized care plans that address specific health concerns, resulting in more effective treatments and enhanced outcomes. This tailored approach is also in harmony with the value-based care model, ensuring that treatments are both necessary and suitable, thereby preventing over-treatment and minimizing the risk of harm from unnecessary procedures. • Data-Driven Decision-Making: In a value-based healthcare framework, providers frequently face the necessity of making intricate decisions influenced by a multitude of factors, ranging from patient history to the most recent research findings. Descriptive analytics can facilitate informed medical decisions by offering evidence-based insights, enabling healthcare providers to make more suitable data-driven choices. AI-driven decision support tools can also recommend the most effective treatments based on patient data, while machine learning algorithms can uncover patterns in patient health that may not be readily apparent. This empowers clinicians to make more precise and timely decisions, ultimately resulting in improved patient outcomes. • Measuring Care Value: In a healthcare system focused on value, success is determined not by the quantity of services rendered but by the satisfaction outcomes of patients. Advanced analytics can assist healthcare organizations in evaluating and monitoring the genuine value of care by examining the correlation between patient outcomes and care costs. By assessing both quality and expenses, descriptive analytics enables organizations to pinpoint which practices offer the greatest value to patients. Case Studies and Examples: Practical implementations of advanced analytics in value-based healthcare are already yielding remarkable results. For instance: 1. Predicting Hospital Readmissions: Numerous hospitals employ predictive analytics to identify patients who are at risk of being readmitted within 30 days post-discharge. For example, certain hospitals have effectively utilized machine learning models that scrutinize patient data, including prior medical history, comorbidities, and discharge notes, to forecast which patients are most likely to return. This empowers healthcare providers to be proactively informed with additional care or follow-up, thereby mitigating readmission challenges and enhancing patient outcomes. 2. AI Technology in Oncology: In the field of oncology, AI is utilized to tailor cancer treatment. By examining data from medical records, genetic profiles, and clinical trials, AI algorithms can propose personalized treatment plans suited to individual patients. This aids oncologists in selecting the most effective therapies, ensuring proper scheduling, and increasing the likelihood of successful outcomes. 3. Improving Population Health Management: Healthcare organizations are leveraging advanced analytics to discern patterns and trends within extensive patient populations, allowing for more effective management of chronic conditions. By analyzing patient data across entire communities, providers can establish proactive care programs aimed at at-risk populations, ultimately reducing overall healthcare
Top 7 Advantages of Embedded BI in Healthcare
The healthcare sector is a field characterized by continuous changes driven by new technologies and methodologies aimed at enhancing patient care and optimizing administrative processes. A notable advancement in this area is healthcare business intelligence, which incorporates integrated analytic tools for data analysis. Healthcare BI significantly enhances the efficiency and effectiveness of healthcare services and systems in an automated manner. Embedded Business Intelligence includes comprehensive data gathering, analysis, storage, processing, along with visualization, predictive analytics, and performance management facilitated by sophisticated reporting. Furthermore, BI is crucial for healthcare providers, enabling them to make informed clinical decisions that lead to improved patient outcomes, address financial challenges, and manage operations effectively. In this blog, we will examine seven key benefits of embedded BI in healthcare and how these elements work together to foster a seamless and efficient healthcare experience. 7- Key Benefits of Healthcare Business Intelligence 1. Improved Patient Care and Outcomes: One of the most significant applications of business intelligence for healthcare providers is the enhancement of patient care and outcomes. The incorporation of embedded business intelligence in the healthcare sector enables users to obtain real-time data and analytics seamlessly integrated into their workflow. This immediacy empowers physicians, doctors, and other medical professionals to gain insights into a patient’s medical history, diagnoses, and laboratory reports. By embedding analytics directly into patient management systems, healthcare providers can identify patient risks and take proactive measures to mitigate them without the need to switch between different systems. For instance, predictive analytics driven by embedded BI can pinpoint patients at risk of developing specific conditions or complications, facilitating timely interventions. Early detection of chronic diseases such as diabetes or heart conditions can result in improved long-term outcomes for patients. Tip: The Self-Service BI tool is also accessible to patients, granting them prompt access to their personal information. 2. Enhanced Operational Efficiency: Healthcare organizations are intricate, comprising numerous departments and systems collaborating to deliver patient care. Integrated BI tools can significantly improve operational efficiency by offering insights into hospital workflows, resource utilization, and overall staff performance. Healthcare professionals can leverage data-driven insights to optimize staff schedules, minimize patient wait times, and ensure that medical equipment and supplies are adequately stocked in advance. Moreover, business intelligence software tools assist in pinpointing areas where resources may be underutilized, enabling healthcare administrators to allocate resources more effectively. This results in smoother administrative operations and ultimately enhances the overall patient experience. 3. Real-Time Insights for Prompt Decisions: One of the most notable benefits of embedded BI is its capacity to provide real-time data and analytics access at any time and from any location. In the healthcare sector, decision-makers require up-to-the-minute information to make critical decisions. Embedded BI integrates effortlessly with Electronic Health Records (EHR) and other clinical systems, providing healthcare providers with immediate access to patient data and actionable insights. Real-time access empowers healthcare professionals to make quicker, more informed decisions, whether in an emergency situation or during routine patient care. For instance, having access to a real-time view of a patient’s vital signs can assist healthcare workers in identifying potential issues before they escalate, thereby improving response times and patient outcomes. 4. Cost Reduction and Revenue Management: Healthcare providers face ongoing challenges in managing costs while ensuring high-quality patient care. Embedded BI is crucial in assisting healthcare organizations in lowering operational expenses by offering insights into financial data. By pinpointing inefficiencies, waste, or excessive resource utilization, healthcare administrators can make well-informed decisions to enhance spending efficiency. For example, BI can scrutinize patient billing data to verify accuracy and identify potential revenue losses stemming from coding mistakes or overlooked charges. Additionally, predictive analytics aids healthcare organizations in anticipating expenses and budgeting more effectively, ensuring that resources are allocated to areas of greatest need without incurring unnecessary costs. 5. Internal Collaboration and Communication: Effective teamwork and communication within healthcare teams are essential for delivering high-quality care. Integrated Business Intelligence (BI) promotes seamless data exchange and collaboration by providing a unified perspective of patient data, thereby enhancing communication across different departments and specialists. Healthcare professionals from different departments, including doctors, nurses, administrators, and lab technicians, can access the same data, minimizing misunderstandings and enhancing teamwork. This method of data sharing fosters improved decision-making, coordinated care, and quicker resolutions to patient concerns. 6. Automated Regulatory Compliance and Reporting: The healthcare sector is governed by numerous regulations and standards, such as HIPAA and CMS, which mandate that healthcare providers uphold stringent data privacy and security measures. Embedded Business Intelligence (BI) supports organizations in maintaining compliance with these regulations by automating the processes of data collection and reporting, while also ensuring that the system is updated in accordance with any future modifications. Through the implementation of embedded BI, healthcare providers are able to produce precise, real-time reports for audits and regulatory submissions. By centralizing and automating data management processes, healthcare organizations minimize the likelihood of errors and guarantee adherence to compliance standards. Furthermore, BI tools enhance the tracking and management of patient consent forms, medical records, and other compliance-related responsibilities, thereby simplifying the task for healthcare providers to remain compliant with legal obligations and avoid incurring costly penalties. 7. Enhanced Research and Disease Prediction: Embedded BI represents a significant advancement in the realm of predictive analytics within healthcare. Utilizing sophisticated algorithms, embedded BI tools can scrutinize extensive datasets to predict patient outcomes, recognize trends, and issue early alerts regarding potential health concerns. For instance, hospitals can employ predictive models to foresee patient readmissions, allowing healthcare providers to implement preventive measures such as follow-up care, early interventions, or tailored treatment plans. Additionally, predictive analytics can contribute to more effective management of chronic conditions, leading to a decrease in hospitalizations and an enhancement in long-term patient outcomes. Final Thoughts Embedded BI is revolutionizing healthcare by providing data-driven insights that enhance patient care, streamline operations, and improve financial management. From immediate access to patient data to predictive
Changes in OB GYN Billing Global Periods: What You Need to Know
Only one specific area has been modified. In 2025, new telehealth CPT codes were introduced; however, the adoption by Medicare remains limited. Being aware of these updates safeguards your revenue and ensures compliance, as improper obstetric global billing consistently ranks among the leading causes of claim denials. What is a Global Period in OB GYN? Global-period billing includes prenatal, delivery, and postpartum services consolidated into a single bundled reimbursement for obstetrical care. Instead of billing individually for each prenatal appointment, delivery, and postpartum care, you submit one all-encompassing code that addresses the complete pregnancy experience from the initial prenatal visit to the concluding postpartum examination. The global package typically includes postpartum care for six weeks following delivery, after which additional visits necessitate separate billing. This is distinct from surgical global periods that utilize specific day counts, such as 10-day or 90-day periods. OB-GYN global billing encompasses the entire range of routine pregnancy care, irrespective of duration. Core Codes You Need to Know Global Package Codes Utilize when your practice provides comprehensive pregnancy care: 59510: Cesarean delivery with complete care. 59610: Vaginal birth after previous cesarean with complete care. 59618: Cesarean after attempted VBAC with complete care. Component Codes Utilize when you only manage part of the pregnancy care: 59409/59514: Delivery only (vaginal/cesarean). 59425: Antepartum care, 4-6 visits. 59426: Antepartum care, 7+ visits. 59430: Postpartum care only. Decision Rule: Did you only manage certain aspects while other providers took care of different parts? Utilize component codes. New Telehealth CPT Codes with Limited Medicare Recognition New CPT codes have been introduced for the year 2025, which include 98000-98007 (audio-video), 98008-98015 (audio-only), and 98016 (brief communication). These codes inherently represent telehealth services and do not necessitate modifier 95. However, Medicare currently acknowledges only 98016; 98000-98015 are not reimbursable by Medicare (although some commercial plans may cover them). Virtual consultations that are included in standard prenatal or postpartum care continue to be part of the global package. They cannot be billed separately merely because they are performed through telehealth. However, telehealth consultations for complications or issues that fall outside the standard global package may be billed separately using the relevant evaluation and management codes or code 98016 when applicable. What Did NOT Change? CPT codes remain unchanged from 2024. Global package regulations have not altered. Bundling principles remain consistent. The regulations regarding split and shared visits will persist from 2024, upholding the same substantive portion requirements and the use of modifier FS (applicable only to facility settings). Services that were eligible for separate billing in 2024 will remain eligible for separate billing in 2025. Telehealth Rules for 2025 Bundled services will remain bundled irrespective of the delivery method. Routine prenatal telehealth appointments, virtual postpartum check-ups, and standard pregnancy education sessions held online are encompassed within your global package payment. What Can You Bill Separately? Telehealth visits addressing complications. Virtual care for unrelated medical issues. Coding Requirements Utilize service code 02 for alternative telehealth locations or 10 for a patient’s residence. For traditional E/M codes, most commercial insurers require modifier 95, although Medicare requirements differ by MAC. The recently introduced telehealth CPT codes (98000-98015) do not necessitate the use of modifier 95, as telehealth is inherently encompassed within the code description; nevertheless, it is crucial to highlight that Medicare does not recognize these codes. Important Note Medicare’s expanded telehealth flexibilities (including home as the originating site) are effective until September 30, 2025. Code 98016 supersedes HCPCS G2012 for brief communications. Making the Right Choice: Global vs Component Codes Use Global Codes When Your practice manages the entire pregnancy. Use Component Codes When The patient transitions between practices. You only perform delivery without providing prenatal care. Another practice manages postpartum care. Real Examples A patient moves to a different location during pregnancy: The initial practice charges for the antepartum code, whereas the new practice charges for the global code. Hospital delivery involving a different obstetric group: The prenatal practice charges for the antepartum code, while the hospital group charges for the delivery-only code. You handle the call and provide an unknown patient: Charge the delivery-only code. Essential Modifiers for 2025 Essential Modifiers You Should Use Modifier 25: Significant, separately identifiable E/M service on the same day as another procedure (note that this modifier is often misapplied in OB claims, so ensure proper documentation). Modifier 95: Telehealth services when utilizing traditional E/M codes (not required for new telehealth-specific CPT codes). Modifiers That Don’t Belong on OB Claims Modifier 90: Laboratory services for reference (not applicable during global periods). Modifier 91: Laboratory tests repeated (not applicable during global periods). These laboratory modifiers are irrelevant to obstetric global billing and can cause confusion in claims. Understanding Various Payer Requirements Medicare’s Strategy for OB Global Billing Medicare employs the “MMM” indicator for obstetric global packages, setting them apart from surgical global periods. Telehealth coverage remains available until September 30, 2025, allowing patients to access services from home without geographic limitations. Commercial Insurance Differences Many insurers align with Medicare’s guidelines but may exhibit particular variations: The precise number of postpartum visits included. Distinct telehealth stipulations. State-specific regulations (such as North Carolina’s new F-codes effective after July 1, 2025). It is essential to confirm the policies of individual payers instead of presuming consistent coverage. How to Accurately Bill for OB/GYN in 2025? Standard Pregnancy Care The patient receives comprehensive prenatal care, undergoes delivery, and completes postpartum care within your practice. Code: Employ the correct global code (59400, 59510, etc.) Mid-Pregnancy Transfer If a patient transfers to your practice at 28 weeks, you will provide continuous care and delivery. Code: Apply the global code as you have delivered significant antepartum care along with the delivery. Telehealth for Postpartum Complications Should a patient experience postpartum depression necessitating a virtual consultation beyond standard care? Code: Utilize the appropriate E/M code
How Long Does Credentialing Take?
If you operate a healthcare practice, you are likely well-acquainted with the various components of the healthcare system and its processes. Some of these components occur rapidly, while others may take longer to develop. Credentialing represents a vital and important phase in the onboarding procedure for healthcare professionals. This process is also referred to as provider credentialing, medical credentialing, and physician credentialing. It entails a thorough verification of healthcare providers to confirm that they fulfill the necessary criteria for delivering quality services. However, it is important to note that this process can be quite time-consuming and may require more time than healthcare providers typically anticipate. If you are interested in understanding the duration of the credentialing process and the primary factors that may cause delays in provider credentialing, we encourage you to read this article. Additionally, you will discover effective strategies to enhance the efficiency of the credentialing process. Let us begin! What is the typical duration required to credential a provider? Physician credentialing provides numerous advantages for both patients and healthcare providers. This process ensures that all professional credentials are accurately verified, allowing patients to receive high-quality care. Credentialing specialists are also capable of identifying fraudulent credentials, thereby preserving the integrity of a healthcare practice. Furthermore, a more expedited credentialing process enables patients to access the quality care they desire without unnecessary delays. Ultimately, this efficiency allows healthcare providers to receive their reimbursements promptly. Typically, the entire procedure can take several weeks to months to finalize the credentials for healthcare providers. Typically, the duration for provider credentials averages between 90 and 120 days. However, it is important to note that this is merely an average estimate. The precise duration of a provider’s credential is contingent upon several factors, including: The efficiency of the organization’s credentialing process The accuracy and effectiveness of provider documentation The complexity of the provider’s background The method of credential Generally, the anticipated approval times for credentials are as follows: Credentialing for Medicare and Medicaid: 60 to 90 days NPI application: 30 minutes Initial versus re-credentialing times: 90 to 150 days / 45 to 90 days Commercial insurance carrier credentialing: 60 to 90 days (30 days for contracting) Online CAQH application: 3 hours The provider credentialing process should ideally be expedited. If healthcare providers are solely focused on credentials, they may neglect their patients. This can adversely affect the revenue stream of a healthcare organization. If healthcare providers do not meet the credentialing requirements for approval, they will be unable to offer their services. Consequently, the healthcare organization will miss out on the benefits of its professional expertise. Therefore, the medical credentialing process must be efficient and effective, enabling healthcare providers to reach their objectives. What documents are necessary for Credentialing? The initial phase of credentialing healthcare providers entails the verification of all documents submitted by these providers. Credentials specialists are tasked with this responsibility and meticulously review each document. They also conduct primary source verification to ensure accurate assessment. During this initial phase, the following documents are verified as they are crucial for the credentials process. Application The initial application serves as a form that collects all pertinent information, including personal details such as contact information and other background specifics. The processing time for credentialing applications can vary. Education Providers must submit documentation of their educational qualifications, including certificates, diplomas, and similar credentials. Personal identification This category includes the passport, driver’s license, and social security number. Professional documents This encompasses board certificates, medical licenses, and associated registrations, among others. Previous work history Providers are also required to furnish details regarding their past responsibilities, including affiliations with professional organizations, employment dates, and job descriptions. Malpractice insurance Alongside the documents, providers are required to submit proof of malpractice insurance coverage. DEA registration If healthcare providers prescribe controlled substances, they must submit their registration details to the Drug Enforcement Administration (DEA). Criminal record Credential professionals also investigate whether there is any criminal record associated with a provider to avert potential issues in the future. What are the primary steps involved in the credentialing of providers? The primary steps in the credential process are outlined as follows: Information Gathering The initial step entails the collection of the necessary credentials for credential. Comprehensive information regarding healthcare providers is compiled. Additionally, other pertinent details include the physical address, mailing address, individual or group National Provider Identifier (NPI), clinic fax number, Tax Identification Number, Master Provider Index, and so forth. The duration of this step can vary, but it typically spans a few weeks. Creation of a Payer List The subsequent step involves formulating a list of payers and insurance networks with which you intend to contract or participate in their insurance plans. The choice of insurance networks is determined by the preferences and requirements of the healthcare practice. Government Health Plans This includes TRICARE, Medicaid, Medicare, the Children’s Health Insurance Program (CHIP), and VA Health Care. Health Insurance Right Health United Healthcare Cigna Humana Anthem Kaiser Permanente Blue Cross Blue Shield Bright Health Aetna Oscar Health Sidecar Health Lemonade Development of CAQH Profile The CAQH (Council for Affordable Quality Healthcare) is a database that authenticates provider information. Initially, a CAQH profile is established and subsequently maintained. Creating a CAQH profile is highly advantageous as it enables one to apply for credentials at multiple organizations simultaneously. State credentialing application Some credential applications are specific to states and gather information related to education, training, experience, and licensure. Determining the payer’s credentialing requirements The initial step you should undertake before commencing your application process is to ascertain how many payers you wish to collaborate with. Additionally, you should identify the requirements of each payer. By accessing their official website, you can ascertain all specific requirements. Subsequently, you can submit your application accurately. Submission of application Once you have compiled a list of payers and identified their requirements,