What Is Unbundling in Medical Billing

1. What Is Unbundling in Medical Billing?

2. The importance of medical billing isn’t something that we need to restate, but it is something that can be particularly challenging for small medical offices in particular. One of the main issues that healthcare providers, big or small, tend to have with medical billing is something known as unbundling – this is a practice that can lead to things: • – Financial losses • – Incorrect claims • – Even legal trouble • Let’s explore what unbundling in medical billing is in a bit more detail, including why this sort of thing happens and how you’re able to shield yourself from potential pitfalls:

3. Understanding Unbundling in Medical Billing • In essence, unbundling is something that occurs when a healthcare provider or billing department submits separate claims for medical services you’ve provided that should actually all be grouped together under a single CPT code. • As you may be aware, CPT (Current Procedural Terminology) codes are what we use to describe all the medical services and procedures our patients receive from us, so there’s a CPT coding system to go along with this that’s meant to simplify billing while still ensuring that your practice is getting compensated properly for your work.

4. Every one of these CPT codes represents a specific medical service or procedure – whether it’s performing surgery or prescribing medication – and these are the codes you then send to the insurance companies and payers in order to actually process medical bills. • Having said that, in some cases, you might accidentally separate CPT codes to describe parts of a procedure you’ve done that were meant to be grouped under one code – this is what we call unbundling. The end result? Inflated charges for the same patient and incorrect reimbursement for your practice.

5. Why Does Unbundling Happen? • Unbundling can generally occur for a handful of different reasons, so no one will immediately assume that you had malicious intent if this happens to you. • In the majority of cases, unbundling is basically just the result of medical coding errors, whether your practice’s billing team doesn’t know how to code the correct way for certain services or if they simply lack an understanding of the National Correct Coding Initiative (NCCI) guidelines.

6. In fact, the NCCI was actually made with the aim of promoting proper coding practices in order to reduce errors like unbundling, but without the proper training (which can be pretty time-consuming if you’re running a small practice and have all your physicians are occupied with other things), it can still end up being difficult for your billing team to stay compliant. • Unfortunately, though, there’s still the chance that a healthcare provider is intentionally unbundling in an attempt to increase reimbursement for medical services they’ve provided – billing for individual parts of a surgical procedure rather than using the appropriate bundled procedure code (which would

7. end up leading to higher payouts), for example. • It goes without saying that this is a pretty unethical practice, but most importantly, it’s completely illegal and could result in severe penalties. Impact of Unbundling on Medical Practices • If one of your claims is identified as unbundled, there’s a fairly strong chance that it’ll be denied by insurance companies – not only delaying payments but also hurting your cash flow, which can obviously be pretty catastrophic if you’re a small

8. thing, but if you’ve repeatedly been caught unbundling, it can result in the following: • Audits • – Fines • – Possible legal action • – Damage to your practice’s reputation and financial standing • Of course, honest mistakes can happen, but it’s entirely your responsibility for the accuracy of your own medical billing, so just ensure that you’re using the correct CPT code each time if you want to avoid any kinds of compliance issues.

9. How to Avoid Unbundling • Naturally, you’re going to need to have a fairly thorough understanding of the CPT coding system and the NCCI guidelines in order to avoid unbundling, so there are a few things you can do to give yourself a fighting chance: •  – Training your billing staff regularly •  – Conducting regular audits of your billing practices •  – Reviewing medical records to spot any potential issues before they escalate.

10. Consider Partnering with PMN • Tools like EHR systems can be useful when checking for bundled codes, as they notify you if separate claims for a bundled service are submitted. That said, technology alone is definitely not enough here, so it’s paramount that you combine technology with human expertise so you can properly ensure your coding is not only accurate but fully compliant with guidelines like the NCCI. • This is an area where partnering with a leading medical billing company like PMN can be a huge relief for your practice! Our medical billing experts have been handling the billing processes of small practices in California for

11. 20+ years, so we’re well-equipped when it comes to eliminating medical coding errors like unbundling. • Furthermore, our team is trained to correctly apply CPT codes for every procedure your practice makes – even for more complex cases involving multiple medical services provided to the same patient – not to mention that we’re also on the lookout for any changes in the CPT coding system. As such, you’re not only getting accurate claims but can avoid costly denials and delays, too. • Ultimately, we’re here to take all the administrative burden of billing off your shoulders so that you and the limited number of physicians you have can get back to treating your patients directly.

12. If you’d like to hear more about the range of services we can provide your practice – from managing medical bills to ensuring compliance with coding rules – make sure you contact our team today by giving us a call at (949) 215-5055. Alternatively, feel free to book an appointment if you’d prefer an in-person chat at our office in Laguna Hills, Orange County, California.