Why Pro-Fee Coding Is the Next Great Risk to Your Revenue


As we discussed last week, over the past decade, there has been a tremendous amount of consolidation in healthcare. For hospital-owned physician practices specifically, we have seen the number  rise from 35,700 in July 2012 to 80,000 in January 2018. Over the same period, there was over a 70 percent increase in the number of physicians employed by hospitals or health systems. Overall, there are more providers in-network than ever before.

While these providers have brought in new revenue to the hospital or system, they have also added new risks and complexities to medical coding. Prior to being acquired, many providers did their own coding or delegated this responsibility to someone on their staff. The provider or staff member likely did not receive any special training in coding, but the practice was simple enough that they could figure it out. And in many cases, we have seen this arrangement continue even after being acquired.

But now, more and more payers are pushing back on pro-fee coding. They are asking for more documentation, denying claims, and in some cases, asking for repayments.

For the last few years, we have seen hospitals put resources into building a sophisticated coding workflow because of the changes brought by ICD-10. Now, is an opportunity to integrate pro-fee coding into that workflow to increase productivity, and boost clean claim rates across the enterprise.

But before doing so, you need to investigate your pro-fee coding risk.


There are 4 lenses to look through when determining where pro-fee coding adds risk to your organization.

Time Management Risk: Payers are taking a close look at E/M codes, especially those coded at levels 4 or 5. It important to use best practices when coding and ensure that the documentation supports the E/M code being used.

Specialties Risk: Certain specialties carry an increased risk because of the complex rules around their applicable coding.

Procedure Risk: There is also increased risk for certain procedures. Many of these procedures carry modifiers that can influence if an E/M code should be billed or if it is included in the procedure code.

Relative Value Units (RVUs): Certain providers may not be efficiently bringing in revenue for their RVUs, so it is important to monitor their RVUs vs. their billable reimbursements.


Develop a risk score card for each provider in your network. CMS releases non-identifiable bell curves for E/M codes in your area and you should be comparing your providers against the curves. It is easy for payers to identify providers that are outliers, so it is important that you are aware of these providers first.

Audit high-coding providers to determine if their documentation justifies their coding. Each patient is unique, and some visits can be complex, but you need to have the documentation to back these coding decisions.

Educate providers, staff and your coders based on the problem areas identified during the audit process. Audits are an opportunity to provide training to assure that all providers are consistently documenting and following your compliance guidelines.

Integrate providers into your institutions coding workflow to make sure it is processed in a consistent and compliant way. This will make the process more productive and ensure a fresh pair of eyes is looking at the documentation to determine the coding.

Speaking of compliance, loop them in early and often. Have an open communication with them to make sure you are integrating provider networks and coding in an ethical, compliant way.

Finally, partnering with a third-party like MRA, can simplify this process. We can help find high-risk providers, provide auditing services, do your pro-fee coding, and provide training. If you are ready to continue the conversation, contact MRA today.

Subscribe to our MRA Newsletter

Bringing peace of mind to healthcare since 1986

Share this post with your friends

You may be interested in...

AHIMA Approved

This program has been approved for continuing education unit(s) (CEUs) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting of Approved CEUs from AHIMA does not constitute endorsement of the program content or its program provider.