Getting paid for one cardiology visit is a cumbersome task, as it is a multi-step and multi-owner project with hard deadlines. These are surrounded by gate approvals and payers who act like a client and can reject the deliverable on a technicality. A single visit to a cardiology practice can generate several separate deliverables. These include the test, the reading of the test, and each has its own rules.
Cardiology practices can consider payers as clients and the revenue cycle management process as core operations of the team. Managing your revenue cycle like a project helps to meet deadlines and optimize the workflows.
Why Cardiology Billing is a Complicated Project
Office visits, imaging tests, procedures, and implanted-device monitoring – each part is a workstream, and it has its own rules and owner. A project manager knows what a project feels like, especially with four parallel workstreams. Cardiology billing feels the same. The weekly tasks of a cardiology billing team, for example, are:
- Submitting claims for imaging tests
- Billing for procedures done in a hospital
- Billing the office visits
- Ongoing monitoring of implanted devices like pacemakers
Why are these separate workstreams? Because the rules are different, a person who handles the office visits is different from the one who gets an implanted device paid. Let’s build a better understanding with an example of a simple test in cardiology called the electrocardiogram (ECG). This test has two parts: performing the test and reading the report.
When a cardiology practice does the test, it bills for both. However, if a hospital runs the machine for the ECG and a cardiologist from a private practice reads the report, these are billed separately under separate codes. The same analogy applies to project management. If a deliverable splits across two vendors, separate invoices go from vendors to the clients. Sending incorrect invoices will create problems.
When a project manager is working on a task, a wrong step can delay the deliverable. When it comes to billing, missing a prior authorization, which is an approval from the insurer obtained before a procedure is performed, leads to claim denial, and practices are not paid for the claim. The same goes for rule changes in the January codebook; submitting claims based on the old rules leads to denials. Applying this to project management, when the requirements of the clients change during the project, the tasks need to be redone with the latest requirements, and deliverables are then delayed.
Treat Denied Claims Like Project Risks
What is the reason behind a cardiology billing denial? Has anyone thought about it? Denial is not a sign of bad luck. It is a preventable thing if practices think that way. Now consider how a project manager thinks about a deliverable that gets rejected for some reason. It, too, was preventable if the task had initially been done according to the standards set at the beginning. The project deliverable was submitted without meeting a criterion that had been established.
For example, an echocardiogram, an ultrasound of the heart, is billed at a higher rate when all the elements are complete. Missing one element makes it a lower-paid procedure. The criteria had already been established requiring all elements to be included in the documentation, but the deliverable did not meet them.
A project manager will manage the recurring risks by logging them and categorizing them afterwards. Billing has the same numbers: first, how often claims come back rejected after the first submission, and second, how often the cardiology practice can reverse the rejection successfully. So, low rejection rates show the process is clean, and higher rejection rates show that there is a problem in the system. A denial log records every rejection and helps find the root cause of denials as well.
Why You Still Need a Billing Expert
The planning part lies with the project manager. However, experts are needed to get the work done. If you are working on a construction project, you need a licensed engineer. When the PM is done with the planning, the work is assigned to the engineers. The same goes for a cardiology practice, which can plan the workstreams, calculate risks, and devise a plan. An expert biller is required who is well-versed in the rules.
Understanding, with an example of a practice that participates in certain federal quality programs, will make it clearer why expert billers are needed. Starting in 2026, Medicare pays with two different rate multipliers (these are numbers the payer uses to turn an assigned value of the procedure into dollars) depending on whether a practice participates in certain federal quality programs. Two practices can perform the same procedure, use the same code, and can be paid different amounts. A project manager cannot handle this because it is not a planning or process problem. This is related to the knowledge that expert billers have.
Practically, if we consider managing cardiology billing as a project, the practice plans and the biller executes the plan based on industry knowledge. This is why many cardiology practices rely on expert Cardiology Billing Services instead of some generic administrative teams. Lastly, the PM plans how to work on a construction site; the engineer does the work. The same applies to cardiology practices, and the work splits the same way.
The Idea Applies Beyond Cardiology
The analogies we created around cardiology apply, as it is a complex specialty with multiple workstreams. The project management framework applies to all specialties irrespective of their specific workstreams. There is a client, a deliverable, a client who can reject a deliverable, and there are deadlines to meet. The same applies to all practices: an orthopedic practice, a pediatric practice, or a mental health clinic. All these specialties have different workflows based on unique procedures, but they have an identical shape of a project.
Sometimes there is a valid code used to bill for a product, but there is nothing behind it. Consider an example of the flu vaccine. If a pediatric practice bills the product code according to the rulebook and the formulation changed, but the code did not. Now, practices are billing for the product that does not exist anymore. The same drift in the requirements can be seen in the project management domain.
The specialties differ, but the concepts in the project management discipline do not. A medical practice, whether it is a cardiology or a pediatric specialty, that manages its revenue cycle process as a project will yield the benefits in the same way. The same idea applies to the Medical Billing Services for every specialty, and efficient project management prevents denials.
Takeaways
- Tracking is essential as it helps to know where the actual problems are. It helps to find the root cause of denials. Log these denials by the cause and categorize them as well. It helps to find the pattern of the denials, and you can mitigate the risks of losing money.
- The revenue cycle process should be considered as a project with deliverables and milestones. Submitting a claim before the deadline is considered a milestone.
- Each step of the revenue cycle process should be owned by one person. Any step that has more than one owner won’t work. It will lead to missed deadlines and discussions related to who owns what part of the project.
- Review the requirements every year as the codebook changes every January. Careless neglect may lead to claim denials and lost revenue.
Planning, ownership, tracking the risks, and regularly checking the specifications. The revenue cycle, in itself, is a project, and if it is well–managed, the results are surprisingly good.
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Daniel Raymond, a project manager with over 20 years of experience, is the former CEO of a successful software company called Websystems. With a strong background in managing complex projects, he applied his expertise to develop AceProject.com and Bridge24.com, innovative project management tools designed to streamline processes and improve productivity. Throughout his career, Daniel has consistently demonstrated a commitment to excellence and a passion for empowering teams to achieve their goals.