Denial Management Tip #2 – Improve Medical Billing Results with Prevention, Management and Follow-up

Kathy McCoy, MBA August 11th, 2011

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When it comes to claims submissions, medical billing professionals need to be sure they are not living in denial about denial management. The reality is that every denial is an opportunity to maximize collections in the future, if the process is managed well.  In a recent video sponsored by Kareo, noted practice management and billing authority Elizabeth Woodcock, MBA, FACMPE, CPC, laid out a variety of strategies that medical billing professionals can use to improve their reimbursement through denial management. We detailed her tips for denial prevention in a previous blog. In the video, Elizabeth offers more pointers for denial management and follow-up that can greatly improve the results of your medical billing.

According to Elizabeth, accuracy in capturing patient information during the registration process is critical. Every keystroke needs to be accurate – one wrong character or number can trigger a denial of the claim. To reinforce that point, Elizabeth likes the idea of having the front office staff rotate through the billing office to see how their work is translated into claims submissions – and have billers staff the front desk to see how their work is done. Swapping roles, however briefly, provides greater insight and fosters teamwork in getting accurate and complete information.

Using the right codes for medical billing is also crucial to maximizing reimbursement. Charges for the practitioner’s time is literally written in code and if they do not correctly reflect the diagnosis or the services performed, you simply won’t get paid. To see if this is an issue for your billing operation, look at clearinghouse reports and denials from payors to see if there are any trends that consistently derail reimbursement. Correcting those errors could pay big dividends in enhanced cash flow.

Watch Elizabeth’s very informative video now:

Watch another video by Elizabeth Woodcock on Key Performance Indicators: How To Keep Your Medical Billing On Track

Elizabeth Woodcock, MBA, FACMPE, CPC, is an expert, author, speaker and trainer in practice management operations and revenue cycle management whose clients include Kareo medical billing software. She is a co-author of “The Physician Billing Process: Avoiding Potholes in the Road to Getting Paid.” You can hear her speak live in our upcoming webinar on Everything You Need to Know About Maximizing Patient Collections.

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Five Ways NOT to Manage Your Medical Billing

Sara M. Larch, MSHA, FACMPE August 8th, 2011

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Practice management expert Sara Larch writes about the top 5 ways NOT to manage your medical billing

We all love a “Top 10” list whether it is on the David Letterman show or on YouTube.  For this article, I didn’t want the list to include ten items; five is definitely enough when we are discussing the ways NOT to manage your medical billing.  Managing your medical billing operation well is one of the most important ways to increase revenue at your bottom line.

Let’s explore each of the “…ways NOT to manage”:

#1 NOT to:  “Give free credit to your patients.”

You might ask, what does this mean? We don’t give our patients free credit or a loan.  It is true that medical groups are not consciously loaning money to patients. But if you have the following processes in place, you are unconsciously loaning money to patients:

  • Letting patients not provide required information
  • Letting patients not pay at time of service
  • A patient collection cycle that allows too much time for payment

Some medical groups disagree with me about the term “letting patients” and instead want to remind me that it is not the medical group’s fault that the patients don’t provide insurance information when they need it and don’t pay their copays and prior balances.  My response is that better performing medical groups have policies and procedures in place that will ensure that things are done right the first time. In order to stop providing free credit to patients, medical groups need to establish financial policies that they are willing to share with their patients and to enforce.  For example:

  • Patients will provide insurance information or identify an alternative method of paying during the appointment/registration phone call.  When the patient says they don’t have access to their insurance card right now, the medical group will have a standard script that explains to the patient that they are willing to wait for them to go get it.  The medical group staff will go on to explain that when they have the patient’s insurance information at the earliest moment, they are in a better position to make sure the patient’s billing is handled correctly.  If the medical group still does not have the necessary information from the patient two days before the appointment, the policy should state that you call the patient and let them know you will need to reschedule them.  Note: your policy will state that you are only going to do this for non-emergent patients.
  • The medical group’s policies need to address when patients will receive a financial policy that they will sign explaining when payments must be received and what will happen if the policy is not followed, i.e., no new appointments being made, finance charges being added to their bill, etc.

#2 NOT to:  “Measure staff performance against a single financial indicator.”

Setting performance expectations for staff and measuring their performance over time is an important element of managing your team.  As a leader, you must remember that you get what you ask for from your team. 

If the single financial indicator is cash collections and your team is pushing towards an aggressive cash collection goal month after month, they likely will change their behavior to increase cash regardless of how they go about doing it.  Usually, this creates patient satisfaction issues on the telephone and at the front desk, and complaints about the billing team. 

If the single financial indicator is the net collection rate (defined as collections/charges-contractual adjustments), then the medical group is at risk for declining cash collections over time.  How?  The fastest way to improve the net collection rate is to write off collectable balances.  The easiest way for a staff member to do that without drawing attention is by writing off balances as a contractual allowance – at least until the group starts auditing some of the payment posting.

Medical groups need to include more than one financial indicator in their staff’s performance expectations.  At a minimum, I would include:

a) cash collections

b) patient satisfaction survey scores

c) net collection rate

d) claim denial rate – this will ensure that things are done right the first time

#3 NOT to:  “Once the insurance contract is finalized, never look at it again.”

Too often medical groups spend months negotiating a contract with an insurance company only to file it away when it is finished.  Instead the contract’s terms need to be turned into actionable information in the practice management system, for your referral specialists, for front and back end teams, and your physicians.  Payments received must be compared to each contract’s fee schedules on a timely basis. Regular meetings/calls with the insurance company’s representative can help you renegotiate that contract when it is time for renewal.

#4 NOT to: “Ignore the claim denials – we are too busy, just write them off.”

If you have ever said this or heard someone else in your medical group say this, then you have a huge opportunity for increased cash at the bottom line.  Claim denials need to be entered into your practice management system and reported on regularly.  Based on those reports, a medical group must create a denial prevention and denial management program with the following goals:

- Increase the percent of payment from an initial claim by decreasing the claim denial rate

- Reduce the cost of rework by doing it right the first time

-Increase payments from claim appeals by following through on denials within the denial appeal timely filing deadlines

Note:  See Elizabeth Woodcock’s recent Kareo webinar about denial management for additional information.  

#5 NOT to:  “Telling your physicians and staff that all is well with your medical group’s billing performance, when it is not.”

Running a billing operation and optimizing its performance is an enormously complex set of tasks.  It takes someone with great leadership and communication skills to keep everyone informed and moving forward on the medical group’s goals.  It also takes someone willing to share the good news and the bad news (or the not so great news…).  When your billing operation is not meeting industry benchmarks, then there are opportunities for improvement.  In order to achieve that improvement, it is best done with a team of people (physicians and staff) working together. 

Make sure your medical group is avoiding these five ways NOT to manage your medical billing.  Turn each of these into statements of how it should be done.  Evaluate your medical billing policies and procedures in these five areas to ensure you are taking advantage of all the ways to increase your revenue at the bottom line.

Sara Larch, MSHA, FACMPE, is a speaker and consultant in practice operations and revenue cycle management and co-author of “The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid.” She contributed an article on “Strategies for Successful Denial Follow-up in Medical Billing” in our June Getting Paid newsletter, and an article on Denial Management 101: Remember the Basics” in our March Getting Paid newsletter.

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Medical Billing Advisory: Hold Those Hospital Charges!

Betsy Nicoletti, M.S., CPC August 8th, 2011

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Holding and reviewing hospital charges will improve accuracy and decrease denialsIt seems like heresy: hold charges?  Isn’t it the best practice to post charges on the day they were provided and to submit those claims frequently? For most services, yes.  But, for hospital services there are good reasons to hold claims until after the patient is discharged.   Hospital services have a significantly higher error rate than services done in the office.  There are significantly more lost charges and denials for hospital services than office services.   Here are strategies to avoid those denials:

Be aware that the status of the patient may change

When submitting a claim for professional services provided in the hospital, the physician’s category of code (observation versus inpatient) must match the facility’s status.  Otherwise, the claim is denied.  Although it is the admitting physician who writes the order for observation or inpatient status, in practice, the case manager at the hospital decides if the patient meets the criteria for admission.  The physician’s billing status must match the hospital’s status in order to get the claim paid.

  • For inpatient status claims, use these codes: 99221-99223, 99231—99233,  99238, 99239.  This is true for all payers.
  • For observation status claims, use these codes: 99217, 99218—99220, 99224—99226.  CPT rules instruct physicians to use the new subsequent observation visits for patients in observation status who are not discharged the day after admission.  However, most Medicare contractors want only the admitting physician to use these codes, and all other physicians who see the patient in observation status to use office and outpatient codes, 99201—99215.
  • For admission and discharge on the same calendar date, either status, use: 99234—99236.

Get a copy of discharge 99239 summaries

99239 requires that time is noted in the medical record.  It only takes a minute to check for that for each discharge billed with code 99239.  The documentation should read, “I spent XX minutes discharging this patient today.”  The time includes time spent with the patient, instructions for care to caregivers, preparation of discharge records, prescriptions and referral forms.

Check dates of service

Review the entire hospital stay when posting charges, making sure that there aren’t any days when two dates of service were charged or no visit was charged.  It’s easy to catch and fix these before charge posting.  For some admissions, the coder may need to look at the chart to be sure which physician saw the patient on which dates.

Use outside documents for verification

Missed charges, wrong dates of services, emergency surgery forgotten.  In the office, there is an appointment linked to an encounter for every patient.  If a charge isn’t posted, the billers can find it by running an exception report.  In the hospital, most groups rely on physician memory for charging.  Use operating schedules, census reports and copies of admissions or Emergency Department reports to verify that all services performed at the hospital are charged.

Many physicians turn in charges for services regularly and accurately.  Hospitalist groups may use electronic charge capture to minimize delay and forgetfulness.  But some physicians will always require assistance over and above the norm in order to have accurate, complete charging for out of office services.

Review all critical care notes and prolonged services notes

Medicare and CPT rules for prolonged services vary slightly.  CPT simply requires that the total time is documented in the record.  Medicare requires start and stop time for prolonged services, and the additional time must be face-to-face with the patient, not unit time.  For critical care, both CPT and Medicare allow the clinician to document the total time, rather than start and stop time.   Physicians of the same specialty in the same group who are both providing critical care services should report the initial episode of care (99291) only once. Additional 30 minute increments, after 74 minutes of critical care time, may be billed by the initial or subsequent physician on the same day using 99292. 

It is difficult for physicians to keep these detailed and confusing rules straight.  Although most physicians code most of their own services, critical care and prolonged services should get a second look by coders who understand the rules.  Because the rules are complex, and the RVUs high, review the documentation for these services before submitting a claim.

Holding and reviewing hospital charges will improve accuracy and decrease denials.  For these services, it may be necessary to physically review the note or the inpatient chart to determine correct coding.

Betsy Nicoletti, an expert on billing and coding, advises how to avoid denials with hospital chargesBetsy Nicoletti, M.S., CPC, is the founder of, a wiki for physician reimbursement. She is a nationally known speaker and consultant, and can be reached at You can hear Betsy speak in a complimentary recorded webinar presented by Kareo on “What You Can Do to Prepare for Medicare Payment Reductions.” In our July Getting Paid newsletter, Betsy wrote on “From Mad to Glad: Talking with Clinicians about Coding.”

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Best Practices: How to Hire the Right Billing Team for Your Practice

Judy Capko August 8th, 2011

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Physicians and managers dread the day an employee says she will be leaving the practice.  There are just so many challenges to think about: How long will it take to find a replacement, can I find a competent person,  how much training is required and does anyone really have time to dedicate to all this? Regardless of the answers to those questions, the pursuit begins immediately.  But the most effective search begins by setting a good foundation for success.

Learn from the departing employee

Find out why Karen is really leaving and promise to maintain confidentiality.  She may tell you it’s a job closer to home or she is making a career change, but those are vague responses.  It is suggested that you tell Karen you value her opinions about the practice and set up a time the following day to meet with her. You may need to probe to get the real reasons, but it is important to learn from this experience.  It may result in finding out she feels too much is expected of her, that a co-worker is slacking and difficult to work with, or that the job responsibilities have shifted and she no longer enjoys it.  The findings may result in an opportunity to intervene and make positive changes to improve the work environment.

Next, review the job description and ask her if it is realistic and, if not, what changes should be made.  This input will help assess how the position might be improved before beginning the search for a new employee.

Finding the right candidate  

Traditional advertising can be effective, but watch the costs; they can kill a budget. Use the costs wisely by writing a concise and purposeful ad that inspires someone to respond. Such descriptive phrases as “it’s a busy practice” or “demanding, fast-paced” are apt to scare off some candidates.  At the same time, words like “attractive,” “challenging,” “opportunities for growth” are all stimulating to people looking for work.

Turn to on-line message boards through various professional organizations, advertising on Craig’s List, Monster and other electronic bulletin boards, and posting openings on your website.  Asking people to e-mail their resume ensures they are professional enough to have an updated resume.  Networking among your peers and through your vendors will help get the word out, as well.

Carefully review each resume to see how closely the applicant’s education and experience match the requirements of the job description and identify problem signs such as a lack of stability in their work history.  Now it’s time to place calls to schedule interviews with the best candidates.  This is an opportunity to screen the person further to determine if he seems like a good match for your needs.  Does he have a professional attitude and appear eager about the opportunity you present?  Is he willing to bend his schedule to accommodate an interview? These are important clues to pick up on. It’s an indication of future behavioral expectations.

The interview plan 

The final goal is select the best candidate. The processes to accomplish this are critical to your success, including the interview appointment.  For example, did the applicant:

  • Arrive on time;
  • Wear appropriate attire; and
  • Properly complete the application form? 

These are key factors to integrate into the selection process.  After all, if the candidate couldn’t get to the interview on time, there is every reason to believe he will be a tardy employee. If the application form was messy, incomplete or inaccurate, you will be facing those challenges if you hire him.  Don’t compromise on these important facts.

Begin the interview with a short dialogue to make the applicant comfortable, such as, how long have you lived in the community, how far from our office do you live or did you have any difficulty finding the office?  Be sure not to ask questions that invade privacy or that even give the slight hint of possible discrimination.  This includes race, marital status and whether they have children.  Check with your state’s employment discrimination laws.

Then move on to ask open-ended questions to solicit opinions and values, rather than questions that are answered yes or no.  For example:

  • Why did you leave your last position?
  • What did you like most about the job?
  • What is the worst work experience you’ve ever had?

Then ask him to describe his ideal job. 

Next, you will want to tell the candidate about the practice culture and mission, and describe the expectations of the position.  Don’t sugar-coat it.  Let her know exactly what you expect and what the position is all about.  Use the job description to help you compare the person’s skill set to your needs, but don’t show it to her at this juncture.  This will ensure she isn’t tempted to match her skill set to the responsibilities on the description.  She may have stated she has three years of insurance experience, but that is a very general statement. Ask pointed questions to better understand her work background – what specific tasks she performed and what outcomes she was responsible for in her past positions. 

It’s also a good idea to give an explicit problem-solving question that would be relevant for this position.  For example if she is applying for the insurance department, ask her what are the three most important steps required to improve patient collections or how would she identify a claim that needs to be appealed. Once you have nailed down the specific experience, show her the job description and ask her to tell you the tasks on the description that she most enjoys and what is the one thing she likes the least.

Close the interview.  When wrapping up the interview, ask her to rate this opportunity on a scale of 1 to 10.  Make sure you are provided with a list of professional references that include phone numbers. Then tell her when you expect to make a decision and whether you will contact her at that point.

Your final steps.   To complete the evaluation, contact past employers to conduct an appropriate reference check.  Promise to maintain confidentiality and ask a list of defined questions.  If you would like a form designed for this, go to and we will be happy to email you one.

Now you are armed with the information needed to make an objective decision and determine which candidate is best suited for the position.  This is an arduous process, but it is essential to improve your odds in making the best decision.  In the end there are only two primary hiring mistakes:  Either you picked the wrong person or you didn’t provide the training, tools and environment required for the new hire to succeed!

Sample Interview Questions

Here are some sample interview questions to use in your quest for the right billing team:


1.      How do you see the manager’s responsibility in supporting the billing department?

2.      What benchmarks would you use to rate the billing department’s performance?

3.      What role do physicians have in supporting the billing staff?

4.      How do you avoid embezzlement in the billing department?

5.      What training tools are essential to train a coder when she or he joins your staff?

6.      How important do you think it is for a coder to be certified, and why?

Sample Problem-Solving Question for a Manager:

If revenue is plummeting, compromising cash flow, what would you do to fix it? 

Billers and coders:

1.      What role does the practice’s financial policies play in your ability to succeed?

2.      What training is required to be a highly qualified coder, biller?

3.      Tell me what you do on a regular basis to keep your skills honed.

4.      How can physicians help expedite the claims submission timing trends?

5.      What advice would you give someone looking to gain the skills needed for your position?

6.      Can you suggest the three most important benchmarks to rate the billing department’s performance?

Sample Problem-Solving Question for a Biller:

If a physician complains that his revenue is less than his colleagues when he is seeing more patients, how would you go about identifying the reason and coming up with a long-term solution?

Judy Capko advises on how to find, interview and hire the right medical billing team for your practiceJudy Capko is a healthcare management and marketing consultant, speaker and author or the best-selling book: Secrets of the Best-Run Practices. She is based in Thousand Oaks, CA, and can be contacted at In July, Judy wrote on The Financial Mindset – Improving Operations and Profitability

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ICD-10 Training Camp: Dissecting the 2011 ICD-10-CM Official Guidelines for Coding and Reporting

Nancy Maguire, ACS, PCS, FCS, HCS-D, CRT August 8th, 2011

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The official 2011 guidelines for coding and reporting ICD-10 diagnosis codes are provided by The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS); these departments are within the Department of Health and Human Services (DHHS).

 The ICD-10 guidelines can be referenced on the Centers for Disease Control website.

These guidelines are a set of rules giving guidance on how to code encounters using official conventions, notes, and sequencing priority.  There are coding rules that apply to the Alphabetic Index and the Tabular list.  The Health Insurance Portability and Accountability Act (HIPAA) requires adherence to the guidelines when assigning diagnosis codes for inpatient and outpatient encounters.  It is important to note that the chapter instructions take precedence over the official guidelines because the official guidelines serve to accompany and complement instructions given within the ICD-10 itself.

The guideline sections

The guidelines are organized into sections.  Section 1A describes the conventions used in ICD-10-CM to include format and structure, placeholder character, 7th character and abbreviations.  The abbreviations are similar to ICD-9; for example: “NOS” and “NEC”.  Punctuation such as brackets, parenthesis, and colons are unchanged from ICD-9-CM diagnosis coding.  You will still find “includes”, and “Excludes” notes but there is a distinct difference in the application of the “excludes” notes.  In ICD-10, Excludes 1 is a pure excludes note.  It means “not coded here” and the code excluded should never be coded at the same time as the code above the Excludes 1 note.  An “Excludes 2” note represents “not coded here” and the condition with this note is not part of the referenced code above the note.  The patient may have both conditions at the same time and in this case it would be acceptable to assign both the code and the excluded 2 condition together.  Section 1A also defines the use and sequencing of multiple codes with an Etiology/manifestation convention (“code first”, “use additional code”, and “in diseases classified elsewhere” notes).

Section 1B of the official guidelines gives general coding instructions for locating a code in ICD-10-CM that corresponds to a diagnosis or reason for visit.  The level of detail is discussed and emphasizes that diagnosis codes are to be used and reported at their highest number of digits available (3, 4, 5, 6, or 7).  Each unique ICD-10 code may be reported only once for an encounter.  Section 1B also gives instructions for coding laterality, late effects (sequela), and documenting BMI and pressure ulcer stages.

Section 1C describes chapter-specific coding guidelines beginning with Chapter 1, Certain Infectious and Parasitic Diseases (A00-B99), and ending with Chapter 21, Factors Influencing Health Status and Contact with Health Services (Z00-Z99).  Chapter 21 replaces the “V” codes in ICD-9 classification. 

Section II (A-J) has guidelines for selection of the principal diagnosis assignment.  This includes two or more diagnoses, signs and symptoms, complications, admission from observation or outpatient surgery.  It is important to read all section guidelines before attempting code assignment.

Section III (A-C) contains rules for other additional diagnosis.  This includes rules for coding previous conditions, abnormal findings and uncertain diagnosis. The rules for “uncertain diagnosis” such as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, differ by place of service.  The guideline states “code the condition as if it existed or was established”, but, it is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.

Section IV (A-Q) guidelines are for diagnostic coding and reporting for outpatient services.  Selection of first-listed condition and accurate reporting for outpatient diagnosis codes, signs and symptoms, chronic conditions and level of detail are discussed.  This section covers rules for coding diagnostic services only, therapeutic services only, preoperative evaluations, ambulatory surgery, routine outpatient prenatal visits, encounters for general medical examinations with abnormal findings, and, routine health screenings.   

Alphabetic index

The alphabetic index includes the Index to diseases and injuries, Table of neoplasms, Table of drugs and chemicals, and, the External cause index.    The coding process begins with the Alphabetic index.  The alphabetic index in ICD-10-CM is formatted the same way as the Index in ICD-9-CM.  Main code descriptor terms are listed in alphabetic order, in bold type. Then, indented beneath the main term, any applicable additional qualifiers, descriptors, or modifying terms will be shown, in their own alphabetic list.

There are some interesting codes in the tabular list.  An example is R99, Ill-Defined and Unknown Cause of Mortality.  This code is used in very limited circumstances when a patient who has already died is brought into an emergency room or other healthcare facility and is pronounced dead on arrival.  It does not represent the discharge disposition of death.

When reporting “falls” it is necessary to determine the circumstances around that statement. For example, Repeated falls, code R29.6, is for use for encounters when a patient has recently fallen and the reason for the fall is being investigated. But, code Z91.81, History of falling, is for use when a patient has fallen in the past and is at risk for future falls. When appropriate, both codes R29.6 and Z91.81 may be assigned together.

The ICD-10-CM makes a distinction between burns and corrosions.  The burn codes are for thermal burns, except sunburns, that come from a heat source, such as a fire or hot appliance.  The burn codes are also for burns resulting from electricity and radiation.  Corrosions are burns due to chemicals.  The guidelines are the same for burns and corrosions, but separate ICD-10 codes describe a burn or corrosion.

Nancy Maguire, an expert on ICD-10, explains the ICD-10 guidelines for medical billingNancy Maguire, ACS, PCS, FCS, HCS-D, CRT, author of The Nancy Maguire GPS to ICD-10-CM Planning and Implementation Guide, is a nationally-renowned procedural and diagnostic coding instructor, bootcamp trainer, and workshop leader. She has spent more than 30 years as a hands-on coder and has authored countless coding articles and presentations. In her expansive career, she has transitioned from nursing, to coding, to practice management, auditing and consulting. Nancy served as Director of Coding and Reimbursement at UTMB in Galveston Texas for four years. She served the first two terms as president of AAPC in the early 1990s.

Hear Nancy speak in two complimentary archived webinars on ICD-10 presented by Kareo medical billing software: How to Prepare for ICD-10/5010 to Reduce F41.1 (Anxiety Reaction) or Preparing for ICD-10-CM: The Nitty-Gritty of Diagnosis Coding.

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Medical Billing Tip of the Month – August

admin August 8th, 2011

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Fast Method for Checking Eligibility in Kareo

For eligibility checks, most people take the hard route and go into the patient and their case to check the eligibility by each insurance company, going into each separate insurance company. I’ve found a much easier route to this:

  • Instead of going into the account AT ALL, go to the “Patients” drop-down menu at the top of the screen and do a search for the patient name in “Find Patients”
  • Once the list of patients comes up, just choose your patient by clicking on their name (don’t actually go into their account)
  • Once highlighted, hit the “Check Eligibility” button on the bottom of the screen
  • When you do it this way, you have the option to choose which insurance plan you want to check and which case you want to check it on;
  • ALSO, a really neat thing in the eligibility check is the “Service Type” field; you can check by provider or specific type of service to get those benefits only!

This has come in HUGELY handy for us here.  Hopefully this will free up some time for your staff who checks eligibility.

Melissa England
Billing Dept Manager
Complete Balance Solutions Institute for Rehab
Laguna Hills, CA

Thank you to all who entered; please be sure to submit your Medical Billing Tip of the Month to by Friday, August 26 for inclusion in the next round of judging. You could win a $250 American Express gift card if your tip is chosen. Good luck!

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Complimentary Archived Webinar: What You Can Do to Prepare for Medicare Payment Reductions

Kathy McCoy, MBA August 5th, 2011

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If you missed this webinar on July 26, good news – you can watch the recording at any time that’s convenient for you.

Learn how to protect your practice from looming Medicare payment reductions in this recorded webinarPhysician practices face certain Medicare cuts for not participating in CMS incentive programs and possible payment cuts if the “doc fix” for payment calculations isn’t passed. What should practices do in the last half of 2011 to protect their finances? How does this affect your medical billing? This complimentary archived webinar describes key strategies including:

Why you should participate in at least one of the CMS incentive programs
• How to evaluate incentive programs and determine which are best for your practice
• How to review schedule management techniques to optimize revenue
• How and why your practice should collect money for services already provided
• And much more

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Who Should View This Webinar
Private practice owners, office managers, billing managers, billers, billing service owners and others concerned about minimizing the pain of Medicare payment reductions.

About Your Speaker:
Betsy Nicoletti, M.S., CPC

Expert Betsy Nicoletti advises you on key strategies for protecting your practice from looming Medicare payment reductionsBetsy Nicoletti, M.S., CPC, is the author of The Field Guide to Physician Coding and the 2007 Physician Auditing Workbook, as well as founder of She developed The Accurate Coding System to help doctors get paid for the work they do. She simplifies complex coding rules for practitioners and engages physicians in a positive and respectful way, which encourages attention and accuracy in their coding. Besides doing auditing and compliance work, she is a speaker, writer and consultant in coding education, billing and accounts receivable.

Betsy holds a Masters of Science in Organization and Management from Antioch, New England, and has worked in and around physician offices for over 20 years. She became a certified coder in 1999. Betsy is a member of the National Speakers Association, the Medical Group Management Association and the Healthcare Financial Management Association.

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Video Update – Key Performance Indicators in Medical Billing: Tip #2

Kathy McCoy, MBA August 4th, 2011

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When it comes to tracking the success of a medical billing operation, there are many variables that can be evaluated to determine how efficiently revenues are coming in the door. But some metrics are more significant than others. In a recently-completed video produced on behalf of Kareo, noted practice management expert Elizabeth Woodcock MBA, FACMPE, CPC presented her top four key performance indicators, or KPIs, and the metrics related to them that show a healthy billing operation. Kareo periodically sponsors webinars featuring Elizabeth and her common-sense strategies for improving your medical billing and reimbursement. Our first blog on Elizabeth’s KPIs video focused on Tip #1, days in receivables outstanding, or AR. If you want to find out what her second tip is, read on.

According to Elizabeth, your aged trial balance reveals how long it takes on average to receive reimbursement for the services you have provided. She recommends using 120 days as the benchmark to track, with an ideal target of only 11% as the percentage of collections that have reached the 120-day mark. Ideally, then, 89% of your revenue should have been received before reaching that 120-day benchmark. In Elizabeth’s experience, however, that percentage is usually closer to 15 or 20 percent.

What can you do to improve your aged trial balance and bring it more in line with Elizabeth’s recommendation? One key strategy is focusing on your time of service collections. Most patients these days have co-pays or deductibles that they are responsible for, even if they are in your practice’s network. Patients who are visiting the office out of network will have an even larger financial obligation. By implementing collection policies that make it clear to patients that these monies are due when they are seen in the office, you can increase the percentage of revenue that spends zero days in collection.

Of course, claims also need to be as clean and complete as possible with minimal errors. Clean claims will enable payors to reimburse you more quickly, improving your aged trial balance as well as your cash flow.

You can also view Elizabeth’s videos on Top Three Ways To Improve Your Medical Billing and Denial Management. And be sure to join Elizabeth for a live webinar on August 25 on Everything You Need to Know About Maximizing Patient Collections.

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The Patient-Centered Medical Home: An Overview for Medical Billing Personnel

Kathy McCoy, MBA August 2nd, 2011

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How does the trend toward patient-centered medical homes affect the practice and medical billing?The notion of a “medical home” is a simple concept: A place where an individual’s health is valued, looked after vigilantly, cared for based on both science and compassion and managed with intelligence, teamwork and patient participation.

As an ideal, the medical home makes good sense. Have a physician who knows what’s going on with your health, lifestyle, medications, etc. and uses that information to coordinate your healthcare around your individual needs. Have healthcare that works to prevent problems and promote better overall health. Reduce illness, mistakes, unnecessary duplication of services and, as a result, the utilization of healthcare.

It makes such good sense, in fact, that it is at the heart of the current reforms — and transformation — underway with the United States’ healthcare system. It also has more than just common sense to support it. And, like all the coming changes, it will certainly affect the medical billing department. 

Medical home: An evolved concept… and an important, relevant topic

The general concept of the medical home, more completely thought of as a “patient-centered medical home” (PCMH), is nothing new. First introduced by the American Academy of Pediatrics in 1967, the medical-home concept has evolved steadily since then into an operational model. Refinements, guidelines and proposed practice models have emerged over time with involvement from various physician organizations, including the American College of Physicians (ACP), the American Osteopathic Association and the American Academy of Pediatrics. Today, the PCMH model is in operation at multiple sites, a hot healthcare topic and the direction in which our healthcare system is going.

What is a Patient-Centered Medical Home?

As defined by the ACP, a patient-centered medical home is “a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient’s lifetime to maximize health outcomes.” It is an approach to the delivery of primary adult and pediatric medical care intended to…

•     broaden people’s access to care

•     result in better-coordinated care

•     provide better outcomes and overall health

•     reduce the costs associated with patients’ healthcare.

PCMH: Fundamentally different from the current healthcare model

Good medicine will always be good medicine. Follow the science. Do what’s right. Be thorough. Have compassion. Listen. Help people. These aspects of healthcare won’t change, and shouldn’t. Where the medical-home model differs is in what it rewards.

In today’s healthcare system, the delivery of care and the need to contain costs are often in conflict; primary care providers are influenced to constrain patients’ use of services. In the PCMH model, cost containment results from better care and improved patient health, which reduce the need for healthcare services. This, of course, is no small change. But there are specific guidelines as to how it can be achieved.

What are the principles behind PCMH?

In 2007, The Joint Principles of The Patient-Centered Medical Home were released by the nation’s largest organizations of primary care physicians. Together, the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians and American Osteopathic Association have specified the following as the core principles behind the PCMH model: 

•     Each patient has a personal physician. We all should have an ongoing relationship with a personal physician who is trained to provide first contact and continuous, comprehensive care.

•     The medical home is a physician-directed practice. Care is provided by a team of individuals, led by a physician, who all take responsibility for the patient’s ongoing care.

•     The PCMH has a whole-person orientation. The personal physician (the “medical home”) is responsible for providing for all of the patient’s healthcare needs throughout life. This includes providing or arranging for acute care, preventive services, chronic care and end-of-life care.

•     Care should be integrated and coordinated. Patients’ care across the healthcare spectrum—specialists, hospitals, therapists, nursing, home health, etc.—should be seamlessly integrated and coordinated by the personal physician.

•     Patients should have better access to care. Open scheduling, specifically a few openings in the daily schedule, allows patients to be seen sooner… and feel well cared-for. Expanded office/clinic hours can have the same effect. Accessibility via email and/or cell phone is also a key access improvement. 

Other key aspects of the medical home

If not immediately obvious, the concept of a healthcare partnership between patient and physician is inherent in the PCMH model. Indeed, the PCMH model facilitates that partnership and is based on the common-sense and evidence-supported premise that better care results from patient participation and shared, informed decision-making. Accountability is also a central component, including the measuring of outcomes. PCMHs will also make use of advanced healthcare information technology in order to maximize their clinical decision-making, patient-care efficiencies, outcome measurement and the all-important integration and coordination of care.

Preventive care: The most important aspect of any medical home

No matter how it gets parsed, the object of healthcare is good health. Likewise, the single-most important premise behind the medical home is improved health. Improved health means fewer problems, fewer visits to the ER, fewer hospital admissions and fewer of many other costly healthcare services. And achieving improved health involves, in large part, emphasizing the prevention of illness and the careful management of chronic problems. Preventive care is therefore at the very heart of the medical home and a vital part of the recommendations for practices considering embracing the PCMH model. 

As an overview, the above hits the high points. There is a lot more that medical billing managers and staffers should be aware of regarding medical homes, and we’ll be covering it in further detail in future blog posts. Why transition to PCMH? What are the benefits? The challenges? What is the effect on coding, medical billing and reimbursement? Stay tuned!

What do you think about the concept of the patient-centered medical home? Is your practice a PCMH, or planning to be one? Let us know your thoughts in the Comments section below.

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