Practice management Category
By Delly Parham, CPC
Financial challenges are the top concern in practices today. One of these challenges lies in the obligations defined through physician contracts. Understanding the payer side of the industry better, so you can think like a payer, and knowing how they make money and set reimbursement rates, may help you to identify ways to prevent abusive payment tactics and improve your bottom line.
If you are one of those practices hard pressed to find a file drawer with all of the original agreements, addenda, and rates associated with reimbursement, you may end up with rates that do not even cover the cost of bringing patients through the door.
Tips for Overcoming Payer Challenges and Increasing Income
1. Be organized, consistent, and standardize your practice protocols.
- Compile and maintain all original agreements, addenda, and fee schedules in one place.
- Review your contracts with payers annually for rate changes, coding guidelines, policies, and pre-certification and authorization requirements.
- Stay informed of current CPT®, HCPCS Level II, and ICD-9-CM code changes and requirements. Submit timely, clean claims by using the appropriate codes and modifiers.
- Identify and bill the correct payer. Make sure the name and identification number on the insurance cards are the names and numbers submitted with the claims.
- Comply with all requirements for claims submission—including method and mode of submission.
- Evaluate Electronic Remittance Advice (ERA) and Explanation of Benefits (EOB) to detect processing errors, such as:
- Coding changes
- Reimbursement rates and adjustments
- Reason/explanation codes for denial of benefits
- Submit timely, formal appeal letters with supportive documentation.
2. Know your reimbursement rates and how these rates are determined. Your fee schedule is the most important factor in determining how much revenue your practice will generate.
You can better understand payers and how they make money if you understand how they arrive at the reimbursement rates paid to your provider. The reimbursement rates of payers vary in each geographic region and are usually determined by the number of providers in the same specialty in that region, the cost of living, and the product line. For example, a preferred provider organization (PPO) plan may pay a higher rate than a health maintenance organization (HMO) or Medicare replacement plan. This is because the premium your employer pays for a PPO plan is usually higher than the premium paid for an HMO plan.
Like all for-profit businesses, payers are in it to make money and keep it in their own pockets. It’s to their advantage to negotiate the lowest rates possible. If your provider specialty is needed in their network in that geographic region, you are at an advantage in negotiating a reasonable rate. Whereas, if there are a large number of providers in your specialty in your geographic region, negotiations become tougher.
3. Recognize the cause of abusive payment tactics and how to handle them.
The two most common payment tactics used today can best be described as delay of payment, and payment that falls short of the contracted rates.
Delay of payment may be due to a number of reasons, such as:
- Outsourcing by payers. This has increased over the past few years, and may take staff more than an hour to get through to a person who can help resolve a claims denial.
- Appropriate staff. Staff handling accounts receivables must be persistent and must follow through. Otherwise, deadlines for refilling claims may expire.
- Unclear reason codes for denials. A call to clarify the denial reason may be needed. For example, Blue Cross Blue Shield uses a denial reason that reads “OA-133: The disposition of the claim/service is pending further review.” If there is no follow-up, you may never know that this means Blue Cross requires a copy of the reports to review the claim before it’s paid.
Payment that falls short of contracted rates usually is discovered by evaluating the EOBs or ERAs for accuracy, and are usually an action taken by or omission of the payers, such as rate changes or coding changes. Or, the provider may not be linked to the contracted rates in the payer’s system.
Lastly, you may file a complaint with your state insurance commissioner for bulk claims that are delayed beyond state-required time frames. You may also involve your county and state medical societies regarding a pattern of delayed payment, or payment not adhering to coding guidelines or negotiated reimbursement rate.
May 23rd, 2013
By Charitie K. Horsley, CPC
To compete in today’s tough and ever-changing environment, focus on some of the simplest steps to secure payment for services.
Physician practices continue to lag behind other healthcare-related industries in handling patient registration. Dental, optical, and pharmaceutical offices understand and are much better at verifying eligibility and benefits prior to rendering services. Most physician practices continue their routine registration habits, regardless of significant financial loss. Only 50 percent of healthcare organizations verify patients’ information prior to rendering services. Top claims denial reasons continue to be patient registration-related, including:
- Patient not eligible
- Incorrect patient identification
- Coverage terminated
The top five best practice’s procedures for improving your registration quality and point of service collections include:
- Recognize that registration is a financial function. This position must be seen as a key to the financial success of the company. Don’t underestimate the difficulty of the position or necessary skills. Identify the specific skills needed and ensure that your registration staff members possess those skills.
- Pre-register information. Pre-register the patient’s demographic and insurance information either in person or via a patient portal or secure online form.
- Verify benefits and eligibility at least 48 hours before the patient’s appointment. With all of the automation available today, and the latest compliance deadline for Health Insurance Portability and Accountability Act (HIPAA) transaction code sets 270/271 for patient eligibility now in effect, it’s much easier to get needed information to collect these balances at the time of service.
- Secure payment of all patient responsibility amounts at the time of service. Co-payments should be collected prior to rendered services and all other amounts due, including deductibles, should be collected as soon as services are rendered. The use of a pre-authorization form, where the patient authorizes you to draw up to $250 from a credit or debit card within 90 days from the date of service, helps to secure payment if exact amounts are not known on the date of service. Be sure that you have a secure mechanism for storing the patient’s credit or debit card information.
- Perform quality assurance audits on registration staff and processes. Make each piece of data is a measurable component of an overall score and use the quality assurance data to provide a benchmark and set goals to improving registration accuracy and point of service collections. Remember: “What is measured improves.”
A little focus on the front end of the revenue cycle makes a big impact on the end result and ultimately the practice’s ability to get paid for all of the services rendered. Take the time to review and discuss these five suggestions in depth and you will be surprised at your performance and ability to make measurable improvements.
April 19th, 2013
By Pimmie Lopez, MBA, FACHE
Each medical practice has a unique work culture that’s represented by the beliefs, thought processes, and attitudes of its employees, as well as the ideologies and principles of the practice. Staff and providers generally consider the environment of communication in the practice as their work culture. They often describe it as friendly, casual, open door, close-knit, etc. However, this perception represents only a fragment of a practice’s actual work culture. By true definition, a work culture is far broader as it also encompasses the practice’s ideologies and principles.
High performing practices recognize the importance of instilling their ideologies and principles in the work culture. They accomplish this through well-developed mission, vision, and values statements that are both understood and embraced by their staff and providers. In these practices, staff and providers inherently function as a close-knit team and consistently strive to provide optimal patient care.
The good news is that there is no added cost for improving a practice’s work culture, as it merely involves an investment of time and attention by practice management. And, resulting improvements aren’t limited to the financial bottom line. They actually permeate throughout the practice. Noticeable improvements are realized in work output, customer service, clinical care and job satisfaction. Here are five helpful approaches for developing a high performance culture in your practice:
- Purpose Statements – Develop mission, vision and values statements that are specific for your practice, even if the practice is part of a larger organization. The most effective purpose statements are developed through the active involvement of staff and providers. The ideologies and principles of the practice are more clearly understood and supported by participating staff and providers during the development process.
- Benchmarks – Learn the performance benchmarks for your specialty. Extensive production and cost information is available through the Medical Group Management Association (MGMA). Compare your practice’s performance to best practice benchmarks and establish improvement goals to be achieved in steps over a reasonable period of time. Provide progress reports to the staff and providers and celebrate successes.
- Engagement – Staff and providers should be actively engaged in practice improvement opportunities as much as possible. By doing so, they not only feel more valued, but they’ll become personally invested and supportive of final decisions. Engagement builds stronger teamwork in the practice.
- Accountability – Performance expectations should be clearly established for every staff member and for each service area. Performance and behavioral related issues should be promptly addressed by the practice manager to ensure that patient service is not compromised and that optimal staff support continues for providers.
- Training & Development – Invest in the ongoing training and development of your staff. They not only gain needed knowledge and skills to perform their work more effectively, but they find their learning experiences particularly enriching, thus contributing to even higher job satisfaction.
The process of culture development isn’t nearly as difficult as it may appear to be and practice managers consider it one of their most rewarding experiences. Simply said, the return on investment (ROI) in time and attention is second to none.
April 17th, 2013
There are plenty of reasons an insurer might deny your claims, but the most common billing errors are also the simplest and easiest to correct. Here are the top 3:
1. Incorrect and/or incomplete patient identifier information (e.g., name spelled incorrectly; date of birth or soc. sec. number doesn’t match; subscriber number missing or invalid; insured group number missing or invalid)
Solution: Verify patient demographic and insurance information at EVERY visit. Ask permission to photocopy the patient’s state-issued identification (passport, drivers license, etc.) and insurance card, so that you are sure to have the proper spelling, group numbers, etc., on hand.
2. Coverage terminated
Solution: Verify insurance benefits prior to services being rendered.
3. Services non-covered/Require prior authorization or precertification
Solution: Here again, you should contact the patient’s insurance and confirm coverage prior to services being rendered. You’ll end up with angry customers if you bill a patient for non-covered charges without making them aware that they may be responsible for the charges before their procedure.
April 16th, 2013
A patient or family member is unhappy. Maybe she is displeased by the wait to see a provider, or felt ill-treated, or doesn’t like the way the business part of her visit went. What to do?
Several academic models are published in clinical and business literature, and a review of the Internet is extremely helpful; but most are simply based on the Golden Rule. If you were she, what would you want you to do?
- Be grateful – First, be grateful your customer feels she can complain and you have the opportunity. Thank the person for taking the time to speak and that this is an opportunity for you and your practice to improve.
- Listen – Regardless of the issue, what the complaining patient perceives is real to her. Let the patient or family member tell you what she thinks is wrong. Don’t interrupt, patronize, or try to out shout her. Maintain eye contact unless you are taking notes, but be sure to focus your attention on her.
- Don’t take it personally – The person is complaining about a problem, not you. Divorce yourself from any negativity she may have and listen for the real issue. Something else wholly unrelated to the issue being discussed or your practice may be behind the anger and frustration. Understand that some people feel that a complaint will only be resolved if they are aggressive.
- Respond positively – Be empathetic. Apologize for the negative experience. When you have natural break in the conversation, reflect back what you think the patient or family member is saying. This lets her know you’re listening and helps clarify the issue. Give her a chance to correct your perceptions.
- Learn as much as you can – Ask clarifying questions so you understand as much as you can. Let her know that the questions are not being asked because there is any question about the veracity of her concerns but that you want to be sure you understand what is happening.
- Log the complaint – Keep a log telling who, what, and why. Leave space to document a resolution and a follow-up date. You can identify legitimate trends from an ongoing log of complaints, which can be traced to process, an error, a provider, or staff member. The complaint is an opportunity to improve the practice.
- Assure follow up. Explain what will happen from there, and ask if she would like to document it on a simple form. Get contact information if you do not have it. Be certain to set a tickler to contact her via email, mail, or phone to communicate progress or resolution to her problem.
- Act – Investigate the issue with providers and staff involved and help develop a solution.
- Make everybody a winner – Seek the best outcome. By giving a little, you win a lot. If all parties feel like something has been conceded by the other, especially in a financial dispute, fairness prevails and the issue should be over.
Sometimes, however, the issue is unresolvable. What do you do then?
You can still listen. Many angry patients and customers just want to be listened to. Let her blow off steam, reflect back to let her know you are listening, and be patient. At some point, you will see an opportunity to explain why the situation cannot be resolved. Be patient; be kind. Never once raise your voice or sarcastic.
Explain the reasons in a way she will understand and never once blame it on a rule, payer, or the government with explaining why. Take time, and look for opportunities to help your patient or family member even if the situation is rigid.
It takes energy, patience, and time, but listening, letting her know of her importance to your practice, and a mutual resolution may be one of the best referral tools you can have.
March 26th, 2013
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