You Can Reduce Denials, Part 1

Lea Chatham January 31st, 2013

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Denials can happen for lots of reasons, and they can eat up staff time, but they have to be dealt with. This is money you are owed for services that you have provided. So, we’re going to spend some time talking about medical billing strategies to prevent denials and things you can do to resolve them when they happen.

First, your practice needs to set some standards, or benchmarks, for denials. What are you willing to write off? Most experts say it shouldn’t be more than 4%. So, if that is your goal – not to write off more than 4% in denials – you’ll need to set up some processes to make that happen.

First, monitor your claims submissions. With electronic claims, this is easier than ever. Check claims submission reports regularly. This will show you which claims are accepted and which are not. You may get two reports—one for the clearinghouse and one from the payer. If that is the case, be sure to review both as soon as you get them. The reports will show you the denied claims and the reason for the denial. Hopefully, it is an easy fix and you can correct it and resubmit.

According to the Medical Group Management Association about 5% of claims get denied, and it is usually due to small mistakes made when scheduling appointments or at check in. So the next step in reducing denials is making sure you have good processes in place at the front desk to reduce errors. This includes verifying patient contact and insurance information. No matter how busy the front desk may be they should always verify patient information, preferably by showing the patient their information and having them visually check it. Verifying eligibility ahead of time is another way to ensure you have accurate patient information and that the patient is covered for services. Most practice management software offer some kind of eligibility verification feature now. If you aren’t using it, you should be. It’s an easy way to avoid denials—and a great way to help you collect co-pays up front!

The second most common cause of denials is inaccurate coding. Physicians make mistakes. The coding process is complicated and it is easy to make a mistake and put the wrong diagnosis code. Use mistakes as an opportunity to educate the provider about what happened so they don’t make the same mistake again. This is an area where electronic health records can be a big help. Many providers find that coding accuracy improves with an EHR.

Tracking denials can also help you reduce them. As you see patterns or problems, you can work to correct them at the source. Hopefully, over time you can reduce your overall denials so staff are spending less and less time on correcting and reprocessing claims. With the trend towards increasing patient due amounts, they will need that time to do other follow up!

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3 Easy Ways to Deal with Difficult Patients at Your Medical Practice

Lea Chatham January 29th, 2013

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3 Easy Ways

There are many types of difficult patient situations. An angry patient may show up in your front office complaining about a bill. You might have a patient who regularly comes in with complaints but really isn’t sick or tends to be non-compliant when you make recommendations. Or perhaps you have a patient who regularly disagrees with your diagnosis and treatments. And many physicians will deal with drug-seeking behaviors or patients who abuse their medications. These difficult patients can test your patience, but there are steps you can take at your medical practice to minimize the impact of these challenging situations.

  1. Easiest: Be consistent. This may seem like a no-brainer, but it can be hard to be calm and steady in the face of a person who is demanding and difficult. In the exam room, don’t disregard your own best judgment or the rules you generally follow to appease a patient. If you do it for them once, they will probably ask again. In the office or at the front desk, be patient, calm and consistent as well. Follow your practice policies and if you are the manager, support your staff if they are following your policies. Always keep in mind that the patient is the problem, and everyone has the patient’s best interest in mind.
  2. Easier: Have a policy and process for dealing with complaints. Having a policy for dealing with complaints and a person who is responsible for handling these situations, can help to quickly diffuse the problem. By immediately responding, taking the person with the complaint to a private room (away from other patients), reviewing their bill and insurance coverage, and thanking them for coming in, you might be able to quickly resolve the problem and reduce the drama.
  3. Easy: End the physician-patient relationship. It may not be easy to break up with a patient, but it is possible and sometimes necessary. It is important to have a patient dismissal policy in place with guidelines about when and how to discharge a patient. Consulting an attorney to set up your policy and draft a dismissal letter can be helpful. If a patient is chronically late, demanding, or disrespectful (these are just some of the issues that can arise), you can and should discharge the patient. In fact, you aren’t doing your practice or the patient any favors by allowing the behavior to continue.

Dealing with difficult patients may not happen often, but when it does, it can really challenge even the best staff and physicians. As with many of the more difficult parts of running a medical practice having clear policies and procedures in place can be a big help. And always remember that if you are consistent and follow through, this too shall pass and you can get back to what you love doing—helping people.

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Get a Handle on Your Contract Fee Schedules, Part 2

Lea Chatham January 24th, 2013

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Rico Lopez, Senior Market Advisor at Kareo

In Get a Handle on Your Contract Fee Schedules, Part I, we talked about the key benefit to setting up your contract fee schedules - knowing what you should be paid for services you provided – and the primary barriers that prevent practices from tackling this project. I told you that I would help you with the legwork and execution. So, let’s get to it!

The Legwork

  1. Payer Mix: Find out your practice’s top 20 insurance plans (number of patients, number of visits, total charges and/or total payments). While I am not suggesting that you load all the fee schedules for your top 20 plans – this exercise may actually surprise you. I have worked with practices in the past that were shocked to find out that 75-90% of their practice volume is from their top 10 plans. If this is the case for your practice, then this project just got significantly easier. Knowing what you should be paid on 75-90% of your business is likely a major improvement from your current situation.
  2. Allowable Fee Schedules: Determine the allowable fee schedules for these top plans and find out the basis for fees. In a survey performed by Kareo last year, almost 70% of the respondents stated that the majority of their payers base their fee schedule on a percentage of the Medicare allowable rate. Even if only half or a quarter of your payers utilize this method, the project just became that much smaller since most practice management systems today provide a feature that allows you to manage fee schedules based on a percentage of the Medicare allowable. Now that you have reduced the number of fee schedules you need, you can focus on acquiring those not based on Medicare. You should be able to find these in your payer contracts or call your payer representative for assistance. If you have no luck with the above, don’t worry, I will give you another option in step 4 below.
  3. Top 100 Procedures: Identify the top 100 procedure codes utilized by your practice. This number is likely to be smaller for the majority of practices. The intent here is to identify 80% of your “primary” procedures. In some practices, these primary procedures may include low volume but high dollar value procedures, special procedures (where the practice has made equipment or staff investments) or other commonly underpaid procedures (if you do not know this one, you will soon after you load your allowable fees and begin analyzing payments). Export this list from your system to an Excel spreadsheet or you can just manually compile it – save it as your fee schedule template.
  4. Hard to Find Fee Schedules: In step 2 above, you should have compiled or at least have a good idea of the source of your fee schedules for your top plans. For those plans where you have not had any luck obtaining your fee schedules I am here to tell you that you probably already have it.
    - Pull the most recent 10-15 Explanation of Benefits (EOB) from the plans where you are missing a fee schedule.
    - Take the spreadsheet template from step 3 and start to fill in the allowables from your EOBs. It may be necessary to pull additional EOBs to complete your table.
    - Save the spreadsheet as a new file with the insurance plan on the file name so you can easily identify it later when you import it to your system.
    - Proceed to the next insurance plan and repeat the same steps above.
    - Organize your fee schedule spreadsheets in a logical folder on your computer for easy access and management. Remember, you may need these files again on the next update and having the previous file will make updating easier.
  5. Validating the Values: While you are compiling your fee schedules, this is also a good time to verify whether your fees are in line with local rates. A good fee schedule to use for comparison is your local Medicare rates since it is based on relative values and already geographically adjusted specifically to your region.
  6. Gain the Knowledge: On this one, there are no shortcuts. You will need to fully understand the capabilities of your system related to importing and managing fee schedules. Since the method for importing fee schedules will vary from system to system, it is best to utilize the training tools provided by your system.

The Execution

By now you have all the information and knowledge you need to import the fees for your primary payers and it is just a matter of execution. Depending on the volume of plans and fees you have to import, it is best to define a realistic schedule to complete this project. Prioritize the project according to your payer mix ranking to guarantee the highest impact to your practice.

After loading all your fees, there is one final item you still need to do – create a reminder task to remind yourself to update the fees. Make it easier on the updates by staggering the reminders so you only tackle 1 or 2 fee schedules at a time. If all your fees go in effect on January 1, then start scheduling the reminders in December.

Next time someone asks you if you know if you are getting paid the correct amounts by your insurance plans, you will be able to answer confidently – Yes!

“There is never enough time to do everything, but there is always enough time to do the most important thing.”   — Brian Tracy, Author and Motivational Speaker

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Get a Handle on Your Contract Fee Schedules, Part 1

Lea Chatham January 23rd, 2013

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by Rico Lopez, Senior Market Advisor at Kareo

When I was a healthcare consultant, I used to get a lot of questions from my clients about whether or not there is “enough” value to loading their contract fee schedules in their system. I always gave them the same puzzled look and answered their question with a question, “Why would you not load it if your system supports loading your allowable fee schedule?”

Let us take a retail grocery store. They know how much they should collect for each item in their store by the price tag on the item or on the shelf, so there is no mystery to what each buyer will pay for any item. When the cashier scans the items at checkout, the expected price comes up and then the checker collects this amount from each customer.

Unfortunately, this is not the case with the majority of healthcare practices. The price that each patient pays for the same exact service can vary greatly depending on the practice’s contract with the insurance plan. And worse, patients with the same insurance plan can have different coverage types and responsibilities, so the amount the insurance pays you can vary from patient to patient – even though they are insured by the same company!

The Benefit
I usually follow up my first question with a second question, “How do you know you are getting paid the correct amount if don’t load the expected payment?” Are you relying on your overworked and overburdened staff to have a “perfect recall” of the correct payment amount for each and every procedure per insurance payer? Or are you like the majority of practices out there and you just accept what the payer pays without ever auditing if those payments are accurate?

Sure, there are billing veterans out there who can blurt out the exact allowable for the majority of procedures for a number of payers, but how many of them work for you? And if they do, are they actually in charge of posting or auditing payments for your practice? If you have one of these seasoned veterans in your staff, then you better hold on to them. But for the rest of the practices out there, you have to do it the old fashion way – rely on viable and reliable methods to ensure that you are being paid what you are due.

Please don’t take this wrong. I am not saying that your insurance payers are purposely paying you incorrectly (though, at times, it does seem that way), but they are still human and mistakes happen. So how do you know that you are getting paid correctly? Are you really going to continue to gamble the financial future of your practice on a belief that every claim you process will be reimbursed 100% of the allowable amount?

The Barriers
So let’s go back to the original question and find out why practices are not loading their contract fee schedules. In a recent surveyed conducted by Kareo, practices were asked about the primary reasons why they have not loaded their contract fee schedules and it came down to three primary reasons:

  1. Time: It takes too much time and effort to do it initially and then more time to update it annually.
  2. Information: They either do not have access to the information or do not know how to get it. Most of the respondents had little luck in finding the data needed to load the allowable amounts in their system.
  3. Knowledge: They do not know how to create the file nor do they know their system well enough to import it.

For most practices, the idea of loading each and every allowable fee schedule for every insurance plan that the practice accepts or contracts may seem unrealistic. After all, committing to it will require time and resources to build and maintain.

But like any worthwhile initiative, it all starts with planning, research and analysis (legwork) before you even begin loading your fees in your system (execution). It is actually in the legwork where you will discover that this is not as
daunting as you originally thought.

Be realistic in planning the execution of this project. For some, this is could be a one or two day project, for others it will require more time. Set a realistic schedule and stick to it. If you find yourself struggling to stick to your schedule due to the demands of running your practice, then regroup and define a more achievable schedule.

In my next post, we will tackle the legwork together and I will share with you tips on where to get all your allowable fee schedules (hint – you may already have it).

“It takes as much energy to wish as it does to plan.”   — Eleanor Roosevelt, Former First Lady

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3 Easy Ways to Keep Your Medical Practice on Schedule

Lea Chatham January 22nd, 2013

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3 Easy Ways

It may be one of the biggest challenges in a medical practice management—staying on schedule. Physicians get sidetracked with refill requests, reviewing labs, returning calls to patients. Patients take up more time than they are allotted. A registration person calls in sick and your front desk gets a little behind. There are a hundred reasons why you might get off track. But once it happens, it’s hard to get that time back. You may find that your practice is slightly behind for the rest of the day. Here are a few simple strategies that might help avoid bottlenecks or turn things around when they start to go south.

  1. Easiest: Set clear guidelines for staff about not interrupting the physician with calls or questions between appointments unless it is a true emergency.  Establish a process for the physician to receive messages and manage tasks as specific times of the day—first thing each morning, at the end of the day, perhaps a break at midday. He or she can take care of refills or return calls during those appointed times.
  2. Easier: Prioritize tasks for staff. Make sure your staff know what their top priorities are so that if they get busy they know what to let go of for the time being. Sometimes people are trying to do too much when they should just be focused on moving patients swiftly through their appointment.
  3. Easy: Do an analysis of your time management, including your scheduling process and task management. You may need to look at your days from nuts to bolts. Is your schedule inefficient? Maybe the problem is that your longest patient visits are at the wrong time of day and they are causing backups everywhere else. Perhaps you providers just aren’t managing their tasks well. For more on scheduling, see our blog post on using your schedule to increase revenue. Many practice management and electronic health record systems offer task management tools. If everyone isn’t using them to stay on top of tasks and priorities, now might be a good time to start.

In the end the most important things to remember when trying to keep things on track are making sure that everyone knows exactly what their role is, what their priorities are, and what they should do if things get busy.  Sometimes the problem is simply that people don’t know what to do next to keep things on track and they flounder.

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Top 5 Questions about Transitional Care Management Services

Lea Chatham January 17th, 2013

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At the end of Betsy Nicoletti’s recent webinar, Everything You Need to Know about Transitional Care Management Services, there were a lot of great questions from attendees. Here are the top five questions and Betsy’s answers:

  1. Q: Are only physician practices allowed to use TMC codes?
    A:  Only physicians, and non-physician practitioners may bill these codes.  A clinician whose scope of practice includes E/M services.
  2. Q: Can two providers bill for TCM?
    A: No. Only one provider can get paid for TCM for a patient. If two physicians submit TCM codes, the first claim received will be paid.
  3. Q: Can we bill TCM for patients returning from hospital to nursing home (either skilled or non-skilled)?
    A:   No because that is not a transition back to the community, and the codes are for transition to home/assisted living/domiciliary care. That is how CMS and the AMA defined the codes.
  4. Q: The two day rule, is this a must? We do not always get discharge notification within 2 days.
    A: Yes, this is a must. You will have work with hospitals to ensure you know when patients are discharged.
  5. Q: Does the first face-to-face visit have to be within 7/14 days? If yes, do we bill for e/m code or TCM code?
    A: The first E/M service does need to be within those time frames.  If you provide only an E/M, bill only an E/M.  If you provide TCM, bill TCM at the end of the 30 day period.

These are just five of the most common questions we received after the webinar. If you would like to review all the questions, click here. Or if you would like to see the recorded webinar, click here.

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Setting Your Medical Practice Fee Schedule Helps Profitability

Lea Chatham January 16th, 2013

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How often do you review and update your practice fee schedule? If you answered “never” or “rarely,” you aren’t alone. Many practices know what Medicare and other payers pay them for services, but they may not have a standard medical practice fee schedule or it might be outdated.

Having a practice fee schedule is an important part of doing business as a medical practice. You need to know what it costs you to perform the services you provide and what you need to charge to make a profit. Even if you provide self-pay or other discounts, it is critical to know when you are making money and when you are losing money. Because in the end, the best patient care in the world won’t keep your business going if you don’t make enough to pay the bills.

The first step in creating your fee schedule is knowing what your costs are. You can conduct your own analysis or hire someone to do it for you. Essentially, you have to figure out what all of your costs are and then use that information to determine what it costs to perform each visit or service. All costs means everything from pencils to rent to salaries. Factor in a margin for profit and reinvestment as well. You will always need a little money in the bank to replace a broken piece of equipment or make an upgrade.

According to an article in the American Medical News by Emily Barry, “Basing your prices on costs plus margin ensures that your fee schedule is built on what you need to stay in business, not on what you think sounds fair. This will make your case stronger when you negotiate with payers.”

The AMA provides a detailed worksheet for establishing your fee schedule once your cost analysis is done. Use their fee schedule toolkit to set your fee schedule. Once you have completed this process, you are much better positioned for profitability.

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Everything You Need to Know about Transitional Care Management Services

Lea Chatham January 10th, 2013

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Wondering about the new Transitional Care Management Services (TCM)?  Wonder no more! These codes (and the requirements that go with them) may mean big changes for a lot of providers, but after this free webinar, you’ll be ready to take advantage of this revenue opportunity. Join Betsy Nicoletti, MS, CPC, as she shares everything you need to know about TCM, including:

  • What the new codes are and the requirements to bill for them
  • Who can bill for TCM Services
  • What you can and can’t bill for with TCM Services
  • And more

Register today!  You don’t want to miss this opportunity.

Register now to learn everything you need to know about TCM Services

Expert Betsy_Nicoletti_advises how to improve your patient collections

About the Presenter

Betsy Nicoletti 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.

Register now to learn everything you need to know about TCM Services

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January Getting Paid Newsletter includes Medical Billing Tips for the New Year

Lea Chatham January 8th, 2013

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The January issue of the Kareo Getting Paid newsletter, out this week, features great articles on the transitional care management services and medical billing tips for the new year. Take a minute to review these useful articles and also be sure to subscribe to the newsletter so you receive it in your inbox automatically.

Getting Paid

In This Issue  

coinsWondering about Transitional Care Management Services? Wonder No More!
by: Betsy Nicoletti, MS, CPC
Many medical practices have heard the news: CMS will recognize new non-face-to-face services in 2013. The new Transitional Care Management Services (TCM) codes defined by CPT and recognized by CMS will provide an opportunity for physicians to be paid for work done coordinating the care of patients discharged from a facility and returning to the community. Read more…

Start the New Year Right … Don’t Let Deductibles Stand in the Way
The fact is that healthcare is changing, and that means new challenges and opportunities. The annual deductible reset may not have to stand in your way. The healthcare reform law includes coverage for a wide range of preventive care
services. Unfortunately, not everyone who has insurance knows that or is taking advantage of it. Read more…

Kareo’s Top 12 Medical Billing Tips of 2012
As we head into 2013, let’s not forget about some of the great tools, tips, and tricks we learned from a few of the industry experts who shared their knowledge with us through blog posts and webinars in 2012. Read more…

Discover how Kareo can Help Improve Your Medical Billing

Case Study

Jim Denton
Kareo has enabled me to treat my patients efficiently and to also get paid for them in a timely manner.”
Jim Denton, Owner and Physical Therapist
Total Joint and Orthopedic Physical Therapy

Educational Webinar:
Everything You Need to Know about Transitional Care Management Services
Thursday, January 15, 2012
10:00 AM – 11:00 AM PST
Betsy Nicoletti, MS, CPC

Register Now

This webinar will provide you with all the information you need to take advantage of the revenue opportunity created by the new transitional care management services codes.

1 PAHCOM CEU Credit for attending live.

Kareo in the News

Just Because It’s Expensive, Doesn’t Mean It’s the Best
Andrew Bronstein, MD, a Kareo user, authors a guest column where he discussed his experience choosing a practice management system.

Top   News & Ideas from the Industry

Ten Ways Patients Get Treated Better
“Experts increasingly are adopting new ways to treat patients that studies show are better at healing the sick, preventing disease, improving patients’ quality of life and lowering costs. Here are 10 innovations that took root in 2012.”
Wall Street Journal, 12/17/12

EHR Adoption & Meaningful Use Progress is Assessed in New Data Briefs
Two recent data briefs reported strong growth in electronic health record (EHR) adoption rates among physicians … and substantial growth in nearly all the individual functionalities associated with “Meaningful Use.”, 12/19/12

HHS Launches Privacy Campaign
The Department of Health and Human Services has launched a mobile health privacy and security education campaign, aimed at giving a framework for providers just starting to use mobile devices.
Healthcare IT News, 12/21/12

Doctors Lean Local in Joining Health Information Exchanges
More small startups are competing with statewide or regional exchanges for physician business, a report finds.
American Medical News, 12/24/12

Trends in Health IT Adoption Among Physicians
The correlation between physician age and technology adoption is very real — and the reasons for it very complex. Here’s how practices can get doctors of all ages on the same page.
Physicians Practice, 12/31/12

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Wondering about the new Transitional Care Management Services? Wonder no more!

Lea Chatham January 7th, 2013

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Many medical practices have heard the news:  CMS will recognize new non-face-to-face services in 2013.  The new Transitional Care Management Services  (TCM) codes defined by CPT and recognized by CMS will provide an opportunity for physicians to be paid for work done coordinating the care of patients discharged from a facility and returning to the community.

CMS has announced its intention of moving from a passive payer of medical services to an active purchaser of quality care.  In support of this mission, CMS implemented many programs over the past years, including the Physician Quality Reporting System and incentive payments for meaningful use of electronic health records.  In addition, CMS has provided bonus payments for some Primary Care Clinicians. But CMS doesn’t just provide incentives: Medicare now imposes a penalty on hospitals with high readmission rates within 30 days of discharge. Payment to a physician for managing the care of a recently discharged payment using the TCM codes furthers CMS goal of improving quality and reducing re-admission rates.

Of course, medical practices won’t receive additional payment for nothing.  The TCM service requires that the practice contact the patient very soon after discharge and see the patient in the office within specified time periods.  Medication reconciliation is required at that visit. The patient must have moderate or high complexity conditions, as described by the Documentation Guidelines. Some of the work described by the TCM codes may be performed and documented by the physician staff, and some work must be performed by the provider.  The TCM codes aren’t limited by what specialty physician may bill them, but a surgeon may not bill for these services when the patient is in a global post-op period.  The practice must wait until the end of the TCM period (30 days) before submitting a claim for the services.   Only one physician may bill for TCM for any one discharge.  Multiple claims for TCM for the same patient will not be paid.

In addition to a face-to-face service after discharge, payment for TCM includes non-face-to-face service by the staff and billing provider with the patient, caregiver, family, home health agency and/or other community organizations involved in the patient’s care.  If education, referrals or other interventions are needed, coordinating these must be done.  The billing provider must obtain and review the discharge summary and follow up on any pending diagnostic tests as part of the service.

Many medical practices are doing the work described by these new Transitional Care Management codes now, but are not receiving additional payment.  Starting January 1, 2013, a group may be paid for this important care.

To get more details on how to bill for TCM Services, join me for a free webinar, Everything You Need to Know about Transitional Care Management Services, on Tuesday, January 15.  I’ll discuss how you can take advantage of this opportunity and make sure you get paid for these services. Register here.

About the Author

Expert Betsy_Nicoletti_advises how to improve your patient collections

Betsy Nicoletti, MS, CPC, is the author of The Field Guide to Physician Coding and Auditing Physician Services, as well as founder of She developed The Accurate Coding System to help doctors get paid for the work they do.

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Welcome to Getting Paid, a weblog by Kareo offering ideas, news and opinions about medical billing and practice management with the goal of making medical billing easier and yes, getting you paid. Visit the Product Blog for more information on our products.

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