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How Medical Billing and Coding Can Impact Patient Access


There are many moving parts when it comes to helping ensure that patients can get access to the therapies they need, but the role of medical billing and coding isn’t always top of mind. To be fair, medical billing seems to grow more complex by the day, and keeping abreast of the changes can be a monumental task.

However, getting billing and coding right can result in fewer claims denials and, most importantly, speed up the time it takes to get a patient onto therapy. Investing time and resources into preventing incomplete or inaccurate claims is critical.

We sat down with Chris Webb, the director of product development at RJ Health, an MMIT company, to learn more about the impact of billing and coding on patient access.  

Q: Speak to the complexity surrounding medical billing and coding. How did we get to this point? What factors have contributed to this complexity?

A: When you’re looking at medically covered pharmaceuticals, they’re handled at a site of care, so you’re walking through the door and the HCP may be asking you, “Do you have any comorbidities?” They’ll check your weight, your blood pressure. They’ll set out a tray for injectables. It’s very complex compared to just handing your script into a pharmacist.

Because of these complexities, there are a number of different coding aspects that go into this. You’re dealing with different ratios, and different links between these individual products and the codes, some of which are done in fluid measurements, such as mLs, or some need to be mixed and reconstituted.

You’re also dealing with a number of different departments. You have the provider, maybe a nurse that’s administering the drug. You have a biller that’s pulling information from an EMR, that then needs to pivot over to a billing system. And that’s just the tip of the iceberg.

Q: How does this complexity negatively impact providers, payers and, ultimately, patients/members? 

A: This complexity can lead to underpayment for the provider. Or it could lead to a complete mismanagement of the code, so it would need to be flagged for manual review on the payer side, which can lead to an even greater delay of payment for that service, which was already rendered by the physician.

This delay may impact the patient’s next treatment. Or, if they are cost sharing, it could result in an incorrect bill and co-pay. 

Q: How do providers and payers focus on people, processes and technology to improve medical billing and coding? 

A: With the advent of all these amazing therapies, you’re taking into account a number of different things: how the drug is administered; whether it’s an IV infusion or IV push; whether the patient needs to be monitored, etc. You have all of these different pieces of information that can now be tied together through technology. But whether it’s through a claim system or an EMR vendor, there’s always going to be a delay, but tools can be implemented to speed up the process.

Zooming out, drugs are dispensed from the manufacturer to the wholesaler, to the provider, and to the member—when the insurance company pays for it—but there could be a lot of hiccups along the way. The biggest goal is making sure everyone is well aware of any challenges that exist for that drug ahead of time, such as prior authorizations, step edits or proper inventory management.

Education is key as it relates to the streamlining of this process and smoothing access to these drugs for our patients and members. Tools that empower our users to enter the information they know and pivot to the proper coding and coverage information—leading to quicker turnaround times for treatment and reimbursement—are critical.

Learn how RJ Health can help simplify billing and coding under the medical benefit.


© 2024 MMIT


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