8 strategies for getting paid at your medical practice!

 Erika Regulsky Tags: , , , , , Practice Management


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Effective strategies by billing veterans!

Being a physician, you have had your own experience with payer tantrums. Any doctor will give you plenty of such experience. You know, that complaining about the lack of resources alone won’t help. But if you get a clear idea, of what rules the payer adheres to that causes the maximum hurdles and to implement strategies to evade the worst payer trick, can help you collect all that you are due.

How can you evade the worst payer trick and the patient’s excuses to pay? The effective strategies recommended by our billing veterans to get paid all that you are due.

#1 It’s time you create an AR management checklist!

According to the Centres for Medicare and Medicaid Services:

20% of the claims submitted are denied and 10% of the claims are lost or ignored

60% of denied, lost or ignored claims will never be resubmitted

18% of claims will never be collected

Medical Group Management Association (MGMA) estimates that payers underpay practices in the U.S. by an average of 7% – 11%.

14 tips and tricks that every practice should know!

Your billing staff should know the performance standard and expectations

Cross-train your staff to teach him more than his specific job

Explain your billing staff the elements of a clean claim and develop a training program

Get an AAPC certified coder or encourage efficient staff members to learn more about coding

Focus on payer relationships and contract management. Don’t miss any problems

Maintain a warm relationship with your payers to well understand their policies

Check the payer contract if it defines elements of clean claim, payment and submission needs, the appeal process, termination causes and methods

At scheduling time, review patient account balances

Prior service, verify patient eligibility, co-pays and deductibles

Verify patient eligibility at every visit and collect co-pays and deductibles upfront

Post charges for all office visits on the date of service.

You can get away with aggressive tactics later if you follow up on outstanding claims early

Set the priority for claims follow up based on amount and age

In reply to patient needs build a structured payment policy

#2 Use your PMS to analyse underpayments!

How confident is your billing staff that you are paid according to the contract? Your practice leaves significant money on the table by not knowing this. There is an option in some PM systems to directly upload payer fee schedule and, you can compare the payment amount to the contract amount on a per transaction basis. Some practices run exception reports to find underpayments. You can take a more modern approach by getting a software program at reasonable rate, for underpayment analysis. And yes, there are third party applications available at inexpensive cost to help you analyse underpayments, and allow you to appeal those.

#3 Develop the best denial management strategy!

It would be the best way to avoid denial if you could find a way to make sure that you create accurate claims. It seems difficult but it is possible.

According to AMA, upto 5% claims are denied and with the implementation of ICD-10, this number is expected to rise by as much as 200%. A better investment in denial management is to providing continuous education to coders, to help them identify the potential documentation errors and enable them to code with highest level of accuracy.

Claims resubmission demands more dedicated time and staff and is more expensive and exhaustive when compared with investment of ensuring first time claims are correct.

Technology is the best tool when it comes to denial diagnosis. The first step to fixing the problem is finding the common link amongst your denied claims. It is very simple but mostly ignored. But if the problem is bigger, more to do with the system, it’s time you need to fix up the department rather than just cleaning claim denials.

In addition to understanding the reason for claim denial, acting on the denial as soon as you are informed and turning the denial around is the most essential. To address claims concerns in a timely manner-spending less time strategizing, for a better communication and overall response time, a best way will be building an efficient claims processing directly with the carrier.

How do you identify the potential area of errors? I would suggest you to look for ways to make your operation more accurate and efficient. It’s not only the practice administrator to be held responsible. Encourage your staff to come up with issues, innovations and suggestions. Those who do billing and coding for you, are the ones to help you find why you are getting claim denials.  Don’t miss their insights.

Some of the common claim denial reasons:

Uncovered patients

Required referral/pre-authorization missing

Medical necessity

Coding errors

The Health Care Advisory Board asserts that 90% of the above denials are avoidable, and more than half are recoverable.

What should be your next course of action in case of claim denial?

Create a case of why should the denial be re-appealed

Get firm documentation to support it

Monitor your data and keep checking it frequently

Find out the doctors/locations with the highest number of write-offs

Frequently keep reviewing billing and coding practices.

#4 It isn’t tough using online payer tools!

Why should you wait on the phone for hours to get the correct reason for denial? It’s better and easy to use tools available on payer websites. Last month Colorado launched a Multi-Payer Data-Sharing Online Tool. The data from all payers that are involved will be linked together in this tool so that providers can login to check all the claims. Dr. Judy Zerzan, chief medical officer and deputy director, Colorado Department of Health Care Policy and Financing (Colorado Medicaid) says, “Right now, I would get, it use to be paper but now more often its email, notifications from different plans saying ‘here are the patients you took care of that had diabetes and how they scored on their quality metrics’ and depending on how many different payers I have seen patients of, I would get eight, nine, or 10 different reports”.

#5 Keep an eye on payer contracts and the end dates!

One of the major reason for underpayment is the complications of the contracts medical practices sign. By not reviewing your contracts well, you are leaving money on the table. There’s a possibility that a physician’s contract contain “most favoured nation clause”. This clause might be there in your contract as follows “Provider shall charge another third party payer as much as or more than the rate charged to Payer for the same services covered in this agreement’s Rate Schedule.” Don’t miss to check the “Evergreen Contracts” which changes itself from one term to the other without any notice.

#6 Get the patient in your battle!

In order to build an effective collection plan, patient education is a must. The patient can be the best ally when you need. In cases where you don’t get any information on why some claims are being denied, inviting the patient to your battle can fetch you the information you looking for.

#7 Why you need to explain your financial policy to patients

You have created a financial policy, but if you don’t explain it to your patients it won’t matter. A maximum of 5 minutes spent in explaining the patient, why your policy demands to collect co-pays and deductibles upfront can fetch you thousands of dollars. Create a different payment procedure for patients with high deductibles. Most practices complain that their front office-staff feel uncomfortable in explaining their financial policy to patients.  Take out an hour daily for your staff and conduct a roll play until they gain confidence in explaining the policies to patients thoroughly.

#8 Develop a concrete collection plan!

How far in advance do you remind your patients on their appointments, co-pays, deductibles and policy term date? The best way to improve collection is that your front office-staff well understands the patient’s insurance coverage and benefits. This can be achieved by doing patient eligibility verification. If you do it right you have the accurate information, it gets easier to collect payments from our patients.

What if the patient walked out before you could collect the payment? Using the U.S. postal services to send bills and followup involves more costs and can take more than 90 days to workout. Patients are more tech savvy, so the better way is to allow your patients access online payment portal. This would improve your collections by a high margin. Some practice use automated mails and collection procedures. This procedure uses a secure email/messages even automated call to ensure patient knows about his balance and has the time to pay it.


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I’m a multi-certified revenue cycle management professional and compliance officer with 20+ years of experience. I contribute articles to leading healthcare publications and journals. I am currently working as Senior Transition Manager, in BillingParadise headquartered at Diamond bar, California. BillingParadise offers Medical Billing Services that intersect perfectly with the EMR/Practice management system you use.BillingParadise has offices in New Jersey, New York, Florida, Georgia, Minnesota, and Texas.


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