Optimizing The Revenue Cycle 10 of 12: Denial Management

Posted by Crystal L. Miner, MBA-HSA, FACMPE on Feb 13, 2019 7:53:00 AM

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.


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Topics: revenue cycle management, Medical Practice Improvement, Medical Coding Services, Denial Management

Optimizing The Revenue Cycle 9 of 12: Payment Posting

Posted by Crystal L. Miner, MBA-HSA, FACMPE on Feb 6, 2019 6:45:00 AM

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
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Topics: revenue cycle management, Medical Practice Improvement, Medical Coding Services, payment posting

Optimizing The Revenue Cycle 8 of 12: Claims Submission

Posted by Crystal L. Miner, MBA-HSA, FACMPE on Jan 30, 2019 7:52:00 AM

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.


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Topics: revenue cycle management, Medical Practice Improvement, claims submission, Medical Coding Services

Optimizing The Revenue Cycle 7 of 12: Charge Entry

Posted by Crystal L. Miner, MBA-HSA, FACMPE on Jan 23, 2019 1:33:00 PM

The authors of The Physician Billing Process: Navigating Potholes on the Road to Getting Paid note that charge entry “is often taken for granted, given the demands of other areas of the revenue cycle, yet it is crucial to ensuring a clean claim and avoiding claim denials.” To optimize this step of the revenue cycle, practice administrators must review three main aspects:


  1. The charge entry process itself
  2. Reviewing and editing charges before they become claims
  3. The practice’s fee schedule


There are many ways to enter charges. Clinics who use technology to automate this process as much as possible are ahead of the curve. From having EHRs that are directly interfaced with EPMs to allowing providers to use mobile applications to enter codes/charges when offsite, the fewer fingers typing charges, the less room for human error. There are many EHR systems that allow practices to create a flow where codes entered by a provider automatically correlate to a charge for the practice management and billing system. This removes the need to manually enter a charge for each CPT code performed during an office encounter.


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Topics: revenue cycle management, Medical Practice Improvement, Charge Entry

Optimizing The Revenue Cycle 6 of 12: Medical Coding

Posted by Crystal L. Miner, MBA-HSA, FACMPE on Jan 16, 2019 7:46:00 AM

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.


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Topics: revenue cycle management, Medical Practice Improvement, Medical Coding Services, Outsourced Medical Coding, Supplemental Medical Coding, medical coding

Optimizing The Revenue Cycle 5 of 12: Documentation

Posted by Crystal L. Miner, MBA-HSA, FACMPE on Jan 9, 2019 7:52:00 AM

We all know the phrase “If it’s not documented, it didn’t happen.” The question is, “how do you document what happened, accurately, in a confusing EHR, in a way that will meet requirements and allow you to get paid?” Not an easy thing to answer but there are a number of tools and resources for providers and administrators to help. Tools range from the EHR to the billing team (internal/external), and utilizing external resources. Administrators must help their providers be knowledgeable of the tools available and the guidelines required.


Accurate documentation is a key to appropriate coding and charge entry which are major parts of the revenue cycle. Administrators should assure that their providers know how to accurately document what happens in their encounters with patients. Today this revolves around a provider’s use of the EHR, as 85% of office-based providers use one. Providers should not be focused on insurance/payer requirements. This is the prerogative of the billing department. Instead, knowing and following coding and documentation guidelines should be the priority. This requires constant training and communication between a clinic’s billing team (internal or external) and providers. 


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Topics: revenue cycle management, Medical Practice Improvement, check-in

Optimizing The Revenue Cycle 4 of 12: Check In/ Check Out

Posted by Crystal L. Miner, MBA-HSA, FACMPE on Jan 3, 2019 7:46:00 AM

When checking in at a hotel, what makes it so painless and easy? The fact you know when to show up and what is expected of you, probably. You told the hotel you would be there on the 12th, and they have a regular check-in time of after 3 pm which works for your schedule. Upon arrival, you tell them your name and give them your photo ID and credit card. You know this is so that they can verify your identity and get paid for the room you are about to use. They may ask to confirm how many nights you are staying, just to be sure, but that is all. Then you sign the paperwork saying you won’t destroy their property and that you authorize the hotel to charge your card, they hand over the room key and off you go! 


Obviously, checking in at a medical clinic will rarely be as smooth as checking in at a hotel, but we could get close. In addition, our collections at the front desk should be just as good. The key is to set expectations for our customers. People coming to see their doctor expect to pay everywhere else they go – why not at the doctor’s office? Times have changed from when insurance companies “covered everything.” The current trend is now for them to cover “after deductible” instead. If we can educate and support patients with this new expectation, we will see smoother check-ins and an optimized revenue cycle.


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Topics: revenue cycle management, Medical Practice Improvement, check-in

Optimizing The Revenue Cycle 3 of 12: Insurance Eligibility

Posted by Crystal L. Miner, MBA-HSA, FACMPE on Dec 28, 2018 7:49:00 AM

With the increase in recent years of patient deductibles and copays, the burden of patient collection has shifted to the front end of the visit. The Front Desk Team is now responsible to know what they need to collect from patients at the time of the visit. It was not that long ago when clinics and patients expected insurances to cover most services performed. Thus, little was collected at the time of the visit and most was left for the Billing Team to collect from insurance companies. It was also expected that patients know which specialty services their insurances did not cover. I remember having and seeing signs posted in waiting rooms specifically telling patients “There are over 1,000 different insurance plans, we cannot know the specifics of yours. Please call your insurance carrier and be aware of your coverage and copays.” This is the case no longer. 


High performers in healthcare have found that the best method for enhancing their patient collections is to perform insurance eligibility checks and gather copay/coinsurance/deductible information before the patient arrives for their visit. A recent Navicure article notes that ‘one of the most important components in today’s revenue cycle is patient eligibility checks and verification.’ However, to know that a patient is eligible for their insurance is only part of the battle. Clinics must then be the ones to inform the patients of their copays, coinsurance, and deductibles. Allowing a patient to arrive for the appointment uninformed can lead to either negative experience for the patient or a negative financial experience for the clinic.

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Topics: revenue cycle management, Medical Practice Improvement, Insurance Eligibility

Optimizing The Revenue Cycle 2 of 12: Scheduling

Posted by Crystal L. Miner, MBA-HSA, FACMPE on Dec 19, 2018 10:24:00 AM

 Appointment scheduling is the most complex, non-regulated, system in a clinic. Why? Because we made it so. The process has become so complicated for most scheduling teams that they need a decision tree whenever it comes time to schedule an appointment. I’ve seen the instructions for scheduling be 16 pages for an eight-provider office and a spreadsheet that was printed on legal-size to assure that every scenario was covered! No wonder the clinical staff is often complaining that the schedule has been “messed up.” It should be noted by everyone in the clinic that the schedule is the gateway to revenue. The more complicated and convoluted this step, the less likely the schedule will be fully utilized and potential revenue will go right out the door. Therefore, the goal should be to reduce the complexity of appointment scheduling thereby optimizing the schedule for full revenue potential.


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Topics: revenue cycle management, Medical Practice Improvement, Scheduling

Optimizing The Revenue Cycle 1 of 12: Registration

Posted by Crystal L. Miner, MBA-HSA, FACMPE on Dec 12, 2018 7:48:00 AM


When you showed up at the hotel on your last vacation, did you have to fill out any information about yourself? For example, where you live, your phone number, or your credit card information? Probably not. You just said your name and gave them your driver’s license and credit card. In return, they said, “Sign here please,” for paperwork that says, “I will not destroy my room,” and gave you your room key. These steps all occurred while asking you how your trip was, why you were there and was there anything they could do to make your stay more enjoyable.


It has been a long time since hotels had new arrivals filling out all their personal information when they came in the door. We have been filling this all out online or over the phone for years. The hotels have our contact information and our payment information before we ever arrive. In most cases, if you don’t show or cancel in time they use that information to charge you a fee. Why aren’t we doing this in healthcare? It is expected everywhere else. Hotels, car rentals, sometimes even restaurants for large reservations. What makes the doctor’s office so different? What can we do to make it easier for our patients and ourselves?


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Topics: revenue cycle management, registration, Medical Practice Improvement

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