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In today’s reality of high deductibles and large patient responsibilities’, patient collections are seen throughout the revenue cycle. When calling to schedule an appointment, patient due balances should be collected while on the phone. Once insurance eligibility is verified, patients should be contacted to notify them of the expectation for them to meet their responsibility at the time of service. At check-in, any uncollected past due balances and co-pays should be collected. Payment at time of service must be an expectation set by the clinic and upheld by staff. Checkout is the time to collect all co-insurance and deduct proportions.
Check-out collections are typically the most difficult for a number of reasons. The first is, naturally, that staff do not know what to collect. Beyond training and utilization of technology to know what a patient insurance coverage, copay, co-insurance, and deductibles are, is the knowledge of the cost of the day’s visit. This knowledge relies on clinic staff and providers getting this information to the checkout team before the patient leaves. If the clinic has not been able to accomplish this a majority of the time, then collection is difficult. One solution, besides allowing patients to leave without any payment, is to estimate an amount owed. The way I suggest clients do this is to review the past year’s appointments and charges for each provider. This combined with the provider’s coding productivity leads to a visual trend and an average charge per visit type.
Many practices find problems with their accounts receivable (AR) at one time or another. The key to optimizing this part of your revenue cycle is to keep a pulse on the health of your AR through consistent monitoring. Days in AR by payer as well as the age of a clinic’s AR will tell much about the health of a clinic’s revenue cycle. Administrators and managers must work closely with their billing team to know the daily, weekly, and monthly status of the clinic’s AR and what is being done to manage it.
While many will benchmark their Days in AR, it does not often reflect an accurate picture of the clinic’s AR health. For example, Medicare should pay in 15 days, but if the state’s Medicaid system or a certain insurance payer is having problems processing claims and has outstanding claims over 90 days, the average Days in AR may still reflect 45. Thus, the practice looks as if it might be slightly high in this measure, but only by looking at the individual payer Days in AR does the true story emerge. Administrators and managers should be wary of this statistical problem and ask to know what the average Days in AR is by payer from their billing system and team. This will show far better the true status of the processing of claims and payment by the clinic’s billing team.
It seems payers these days are finding more and more reasons not to pay clinics in full for submitted claims. From non-covered services to ineligible diagnosis, these reasons for denied claims are varied and differ from payer to payer. What one payer will allow, another requires prior authorization. Administrators and managers must assure their staff know how to read, understand, track and correct denials. Staff must be able to read and clarify an explanation of benefits (EOB) and electronic remittance advice (ERA).
Denial management is the act of managing the claim denials for a practice by determining their cause, correcting them, and putting plans into place to reduce their number. Staff must have the initiative and problem-solving skills to best handle these duties. Managers and administrators should encourage team members to question denials and find new workflows to assure they do not occur. Reporting denials reasons and trends to other teams within the clinic – reception, clinical, providers – will also help with this.
You’ve done the service, sent the claim, now time to post the incoming payment. This is not a step in the revenue cycle to be taken lightly or overlooked. There are a few keys to optimizing payment posting:
- Utilizing electronic remittance advice (ERA) to post directly to the electronic practice management (EPM) system. This removes a degree of human error in regards to data entry. Whenever possible administrators should look to combine electronic funds transfer (EFT) with ERA submissions. This allows clinics to see quicker payments. Staff will still need to verify EFT matches ERA and reconcile each payment. When looking to collect payments via EFT, administrators should be aware of any additional fees payers may add on for this feature.
- If manually posting payments to EPM assure high attention to detail and reconciliation. Staff should be trained on how to read the explanation of benefits (EOB) and remittance advice for any payments not in full.
- Despite manual or automated payment posting, clinics must assure payments match the expected amount to be collected. Whether the amount is equal to the clinic’s fee schedule or the contract agreed amount. According to a 2017 MGMA poll, only 20% of respondents compared reimbursement to contracted rates on a daily basis. Almost 30% were unsure or were unclear on if they compared incoming payments to contracted rates. Administrators and managers should perform due diligence to guarantee they are being paid in full for their services.
- Review adjustment reasons and prepare for denial management and appeals. Administrators should train staff to not accept incoming payments or denials as is without assuring all avenues for full collection have been sought. Best practice is for adjustments to be made during the payment posting process, not before.
- Allocate payments by line item incoming from payers. This helps with tracking, reconciliation, and
A claim is an invoice that the clinic submits to a payer to get paid for the services (charges) performed. Most payers require that the invoices (claims) be submitted to them be in a certain format. Some require that if the invoice contains a specific service (charge) that additional documentation should be submitted. Administrators must have someone on their staff who is aware of these requirements. In addition to these requirements, individual states have their own rules regarding these claims. Knowledge and the preparation taken in the steps prior to this are the only ways to optimize this step in the revenue cycle.
To receive payment from a payer in a prompt manner, clinics must submit a claim free of mistakes and errors. This is usually termed submitting a “clean claim.” 42 CFR 447.45 defines a clean claim as one that needs no additional documentation from the service provider or third party. Below is a list of links to state’s insurance codes regarding claims. Almost all states now have some sort of “prompt payment” regulation. Some of these regulations have definitions regarding clean claims that are to be submitted to insurance companies. Those marked below do not have a specific definition.
Unlike other service industries, healthcare has a complicated medical coding system for the services provided. For example, in accounting one hour of service is a specific cost. A simple tax return is another specific cost. In healthcare, it is rare that we can easily quote that a service will be a specific cost. This is due to the way that we are required to code the services we provide and then bill for them. The rules are dictated by outside agencies on how providers document patient encounters in a specific way, code the encounter a certain way, and then the payers may contradict that. Just another fun day in the world of healthcare coding and billing!
To optimize the coding step of the revenue cycle, medical practice administrators must
- determine who will be responsible for knowing the documentation requirements for the medical codes being used,
- assure that the documentation meets these requirements and
- that the code combinations also meet insurance regulations.
Once responsibility is assigned, how each of these steps will be accomplished must be determined.
Whether you are dealing with a commercial payer, Medicare, or Medicaid, there are certain types of improper claims that should be avoided if you want to reduce your risk of a medical coding audit. That bit of wisdom comes from an entity that ought to know: the U.S. Department of Health and Human Services’ Office of the Inspector General (OIG).
The OIG has released a roadmap to help new physicians avoid medical billing fraud and abuse in the Medicare and Medicaid programs. But this advice also broadly applies to how you approach reimbursement from commercial payers, and can also serve as a helpful reminder for physicians with years of experience in practice.
The agency warns, sternly, about consequences, noting in bold type that “when the federal government covers items or services rendered to Medicare and Medicaid beneficiaries, the federal fraud and abuse laws apply.”
When it comes to medical coding errors, the broad categories of “fraud” and “abuse” have distinct meanings. Fraud involves intentional misrepresentation. Abuse means “the falsification was an innocent mistake, but nonetheless representative,” according to the AMA’s Principles of CPT® Coding, ninth edition.
Fraud. Scary word, right? Well it happens a lot, and if you are not careful it might be happening at your practice right now. “Get a free scooter!” You may remember those words uttered on a commercial that ran continuously a few years back. In August of 2014, the Washington Post broke a story on how the government paid billions of dollars for Medicare recipients to get a free motorized wheelchair. The perpetrators of this scam were intentionally defrauding the government by using loopholes to make huge profits on markups for these chairs.
The wheelchair scam example is an outlier, but it is what most people think about when the topic of fraud is brought to the forefront, but that is just one high profile case. There are many instances of unintentional errors that can occur due to lack of understanding of the many regulations and nuances of medical billing. Consider auditing your providers for compliance and finding opportunities for improvement.
Here are 4 reasons why:
1. Billing Mistakes: still the provider's problem
Medicare and Medicaid audits are an extremely popular topic. Imagining the possibility of having your practice or hospital audited for its billing practices is a daunting thought. How simple it can be for a practice to overlook a coding change to IDC-10 or suddenly fall behind the latest PHI requirements.
Failure to stay on top of the changing landscape can lead to major financial problems down the road and the need to pay back unallowable funds. Daily we hear of OIG audits that are the results of missing a coding change or improper practice policies that can be catastrophic to the financial well being of a healthcare organization.