Medical Billing: How to Get Paid Better – Part II

Judy Capko December 15th, 2010

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How well the medical billing and collection pieces work in your practice is a reflection on your practice’s use of its resources. Getting this right the first time reduces the amount of effort it takes to get you paid timely and properly.

 Where does the revenue chain begin? Some people think it begins when the patient’s charges are entered into the computer system, but in reality the revenue chain starts when the patient first calls your office and ends when the account is paid in full. Let’s take a look at the primary steps and resources needed to get paid better.

The Medical Scheduler

This is the point of entry and it is important to clearly define the responsibility the scheduler has in getting you paid. Since their first duties are to give patients good customer service, answer the patient’s questions and understand the appointment needs, the financial responsibilities can quickly become diluted and appear less important.   

The scheduler’s first cue on relating the appointment scheduling process to finances is the pre-registration for new patients and updating demographics and insurance information for established patients. Teach schedulers the right way to do it:

  1. Collect appropriate and accurate insurance data rather than breeze through it;
  2. Make sure the patient understands if the practice is contracted with the payer or whether the patient will be seen “out of network”, which means he or she will be paying a larger portion of the bill; and 
  3. Document any payment discussions and commitments made by the patient when he called for an appointment.

It is important to call upon your billing department to train schedulers on the nuances of insurances – what information is needed from the patient and what to communicate to the patient that will clarify their financial responsibility – and to do this in a way that keeps the patient and the staff working together.

The Medical Office Receptionist(s)

This comes down to check-in and check-out responsibilities. At check-in, the receptionist needs to go beyond collecting patient registration information – such information needs to be reviewed for legibility and thoroughness. Failure to verify information and accurately enter it into the system can result in costly errors and delayed or non-payment. 

Receptionists need to align their thinking to look beyond the cost of today’s visit and understand how much money the patient already owes the practice. Management has an important role in clearly identifying what the receptionist’s collection responsibilities are and to help them set goals for collections at time of service.

This must be supported by training receptionists to examine patient balances and address this when the patient is in the office. To achieve this, the receptionist must learn how to audit a patient’s account and help patients understand how this balance was accrued. Receptionists also need a clear understanding of the practice’s payment policies and what steps should be taken to ensure the patient complies with these policies. This can be accomplished by:

  • Establishing payment expectations in the financial policies;
  • Providing staff with the skills on how to effectively ask and obtain payment from patients; and
  • Identifying methods to reinforce policies.

Clinical Staff

Physicians, mid-level providers and clinical support staff are critical to providing essential documentation for the care that provided with each visit. Whether this is accomplished with an electronic or paper chart, timeliness is vital to improving accuracy and minimizing the possibility of dropping a service and failure to charge and code (ICD-9) the diagnostic reasons for the visit and the procedure code selection (CPT). Documentation of the contents of the visit is what supports the level of service for evaluation and management CPT code and the need for diagnostic testing and procedures performed.    

The goal is to have documentation for services rendered complete and entered into the practice management system at the end of the day.

Medical Billing and Collection Staff

Each practice needs a coder in residence. This requires someone who has superior knowledge in coding rules and application. The practice needs to make an investment in providing the resident coder with the training to become a certified coder. The AAPC coding certification is acquired through gaining expertise and passing the test provided by the American Academy of Professional Coders, www.aapc.com. Certified coders are required to obtain continuing education credits to maintain their certification. Once this is accomplished your coder will qualify as the “go to” person when there are questions about coding. 

Important responsibilities that can be included in the job description for this position are:

  1. Monitors coding and billing performance including variances between providers;
  2. Obtains continuing education on coding each year [at the practice’s expense] with close attention to changes affecting the practice’s specialty; 
  3. Trains appropriate staff  on coding matters, including changes that affect the practice and its specialty each year; and
  4. Provides formal coding training sessions for new clinicians and new billing staff members within 30 days of hire.

With physicians typically charging a minimum of $400,000 a year [and double that for some specialties], it’s worth protecting your revenue and investing in a resident coder to keep the practice on track with billing properly for the services that are rendered. There’s a big upside to having a sharp coder that helps the entire office understand coding requirements so that you get paid better for what you do.

Once billing is accurately submitted, the arduous job of following up on claims begins.   Following up on claims is where staff expertise pays off big time!

Auditing claims payment and sending appeals is vital to protect the practice’s revenue. Don’t assume the insurance plans are adjudicating claims appropriately. They make errors that result in lower reimbursement for the practice. 

It’s difficult to imagine, but in the United States a whopping 30% of insurance claims submitted are denied, according to Healthcare Business Advisors, LLC, Albany NY 2007 report – and of that 15% are never resubmitted. Guess who gets the short end of that stick? You are right – It’s the practice.

CMS (Center for Medicare Services) reports that Medicare denies 11% of submitted claims and 40% of those are never resubmitted. That’s a huge number. To make it even more interesting, Medicare data reveals 65% of the claims reviewed on appeal result in increased payments. Experts say 50-80% of appealed claims are eventually paid – so fight for your money! 

Top-Notch Staff

The message is clear: Hire the best, let them know what you expect and treat them right. This presents new challenges, as some medical office staff members abandon the practice environment and seek opportunities outside of medicine. To identify ways to appeal to the best candidates, answer a few important questions:

  1. How attractive is our practice opportunity for a prospective employee;
  2. What significant changes can be made to appeal to the best candidates; and
  3. Does our culture truly value staff?

A culture of respect places a high value on staff – respecting them as individuals and for their talents – and it starts top-down. Practice leaders must demonstrate how they value employees in their words and actions. Don’t compromise staff’s value by cancelling staff meetings, allowing physicians’ failure to participate in staff meetings, or by failing to respond to their job needs or delaying purchasing needed equipment so they have tools to do the job better and grow their skills.

Communication is essential to building strong relationships with staff. Make sure staff members understand what you expect from them and provide the guidance to help them meet that expectation. When staff members feel appreciated and know they have management’s support, they will band together to reach higher levels of success.

Staying Ahead of the Curve

Healthcare reform brings many new issues to the forefront; some are obvious, others are fluid and will change over time. Guidelines and regulations will continually change. Those regulations will impact the way physicians conduct their business, the revenue they generate and the overall profits that are attainable.

One thing is evident; physicians are being pushed into the information age and the need to embrace electronic health records to manage internal data and provide clinical data to regulatory agents that will be used for industry experts to define standards of care and quality of services. 

It is the responsibility of physicians (and the administrative staff they depend on) to be well-informed and make prudent decisions in the interest of providing a high level of service and use wise economic practices. Keeping everyone in the office informed about their sphere of influence in both the service and financial component of the practice is just plain smart. Good communication and a clear sense of what it takes to succeed keeps everyone working as a team with a vested interest in achieving practice goals and rising above the nuances of practicing medicine in times of reform.

Your continual challenge will be to improve revenue and manage costs without compromising patient care or services. Methods to achieve this vary, including:

  • Advancing the quality of internal systems and services;
  • Establishing and monitoring clear standards of care;
  • Identifying when it is time to outsource and tap into another level of expertise; 
  • Streamlining processes and eliminate those without value; and
  • Obtaining optimal performance by achieving high morale and impressive productivity.

In the end, the most important factor is creating a culture of value and respect across the continuum of care and across the organization – a culture where everyone wins!

Judy Capko is the founder of Capko & Company and author of the popular book “Secrets of the Best-Run Practices,” Greenbranch Publishing, September 2005. Judy has specialized in medical practice operations and marketing for more than 20 years, and is a certified risk management specialist. www.Capko.com

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