10 Steps to EHR Implementation Success

Lea Chatham July 31st, 2013

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EHR implementation Guide from Kareo

Another study has recently come out indicating that physicians continue to be concerned about the ease of use of healthcare technology. According to that new survey from Wolters Kluwer Health, 56% of the 300 providers who participated are frustrated with technology ease of use. This follows on the heels of the AmericanEHR survey, which showed that satisfaction with EHR ease of use dropped from 61% to 48% between 2010 and 2012.

There are many contributing factors, but two that can have a big impact on satisfaction are selecting the right software and implementing it successfully. These days, selection and implementation are often being driven by factors such as Meaningful Use. While these incentive programs are going to play a role, they can’t be your primary reason for adding an EHR to your practice.

The focus should always be on your business goals like increasing efficiency, improving patient care, and streamlining your revenue cycle. These are the keys to making your practice a success. This means choosing an EHR that is the right fit for your needs and following an implementation plan that is designed to facilitate success.

A good implementation plan can mean the difference between satisfaction and dissatisfaction. From goal setting to training to getting familiar with your device, there are many steps to implementing an EHR and each one has a valuable purpose. Download EHR Implementation: A Small Practice Guide to get ten clear steps to a successful EHR implementation along with hints about how to manage your conversion from another EHR or paper charts.

For more on how to own your EHR implementation process and have ongoing success with your software, view the recent webinar Key Strategies for EHR Success where EHR expert consultant Ron Sterling provides his insights into the process.

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Get the Most from Your Mobile EHR

Lea Chatham July 29th, 2013

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Believe it or not, it is possible to engage your patients with (and in spite of) technology. Dr. Tom Giannulli who designed the Kareo EHR has spent years working on ways to better use technology to be more interactive with patients and increase their involvement in their own care and wellness. He believes very strongly that mobile devices are a key to making this vision a reality and to improving physicians’ satisfaction with EHRs. According to AmericanEHR, dissatisfaction with EHR ease of use has been steadily increasing and now stands at about 37%.

On August 7, Dr. Tom will be discussing what he calls heads-up medicine, a way to engage patients through every aspect of their experience, at an event being hosted by Physicians Practice. He’ll review everything from getting familiar with your device (a key piece of improving usability and satisfaction) to using patient portals to provide lab results (a valuable tool to achieve Meaningful Use and patient satisfaction). As a preview to this event, he has recorded a few short videos. Check out this one on learning to use your iPad.

Tom Giannulli discusses using your iPad for Kareo

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Your Top Denial Management Questions Answered

Lea Chatham July 25th, 2013

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In her recent medical billing webinar, Denial Management: Top Techniques that Get Claims Paid, practice management expert Elizabeth Woodcock reviewed her proven four-step strategy for effectively managing denials and getting them paid. She covered a lot of information, and attendees had many good questions. We’ve selected several good questions to share with everyone.

  1. Where can we get the top 10 denials with a reference to the source of this data? Many payers publish the top reasons for their participating providers. The American Medical Association produces an annual report card that includes the top reasons; please see http://www.ama-assn.org/ama/pub/physician-resources/practice-management-center/health-insurer-payer-relations/national-health-insurer-report-card/denials.page.
  2. What is the best solution for claims status—calling, online, or written correspondence? To review claims status, the most efficient solution is to make the query online. If there is a problem with the claim, then make contact by telephone. If the issue can’t be resolved with a customer service agent at the payer, then make your case in written correspondence.
  3. Most of our denials are the result of the incorrect information we receive from the payer when we verify benefits. Are there ways to help prevent this? Unfortunately, insurance companies don’t always have the most accurate information when you request benefit information. A patient may have left a job and that cancellation hasn’t shown up in the payer’s system yet. Or there has been some other change that hasn’t been processed. Although there are challenges, it is still always better to check eligibility and verify what you can. I also recommend asking patients when they schedule and when they check in if there have been any changes to their insurance. It never hurts to complain to the payer if you find this to be a problem, and please do have a process to swiftly contact the patient after receiving a denial despite the verification of benefits.
  4. Is it okay to bill a patient if all the research has been made to get a denial paid and you cannot reach the patient by phone? No, unfortunately not. When you receive a denial returned to you, the Claim Adjustment Reason Code will be accompanied by a two digit alpha—CO for “contractual obligation” and PR for “patient responsibility.” If the denial is reported as a “CO,” the payer is indicating that you have a contractual obligation to accept the non-payment. Only if there is a PR can you transfer the balance to the patient. Now, you certainly can communicate with the payer and argue your case, but most denials must be handled directly with the payer.
  5. What are your thoughts on working your A/R based on payer turnaround. For example, Medicare pays in 14 days and Blue Cross pays in 21 days so should we work these within 3 days after the normal clean payment? Following payers’ payment cycles is certainly “best practice”; I think it is reasonable to follow up three to five days after you expect the payment to arrive.
  6. How do I rebill a claim without getting denied for a duplicate claim? I would recommend following the procedure for resubmitting a corrected claim as outlined by the payer; this is often referred to as the “reconsideration” process.
  7. We have many requests for medical records from one insurance company. They request medical records on almost all claims. Is this legal? It seems like a delaying tactic and am considering going to the board of commissioners. I assume that this payer is requesting medical records before payment. (If they are requesting them after payment, that is another issue.) If you feel that this payer is stalling, I would contact your designated provider representative and state your concerns verbally. Then, I would send him/her a letter. I would then ask your physician to contact the payer’s medical director and, again, report it verbally and in writing. Either on this letter to the medical director, or in a separate letter, I would carbon copy the state insurance commissioner.
  8. Our provider sees a lot of out-of-network patients and has had trouble getting the patient payments. What would be your recommendation to collect this money more efficiently?There are many best practices for collecting patient payments. Here are a few suggestions. First, it’s important to have a patient policy in place that states that patients pay co-pays and other patient responsibility at the time of service. It can be at check-in or check-out depending on the situation. It should also lay out self-pay requirements. Preferably all self-pay amounts should be at time of service. Barring that, you might consider offering discounts for self-pay patients who pay within a period of time such as 30 days or charging late fees for those who don’t. You can also let patients know about balances due when they schedule an appointment. While there are other strategies, these are a good starting point.

If you missed this informative webinar, you can view the recording or the slides. And if you found this event to be valuable, register for our next live webinar, Patient Centered Practice: Guiding Principles for Changing Times.

About the Speaker:

Expert Elizabeth Woodcock will explain best practices for appealing denied claims

Elizabeth Woodcock, MBA, FACMPE, CPC is a professional speaker, trainer and author specializing in medical practice management. She has focused on medical practice operations and revenue cycle management for more than 20 years.

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What’s the State of Your Medical Billing Denials?

Lea Chatham July 22nd, 2013

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Elizabeth Woodcock discusses strategies to get denials paid for Kareo

The Medical Group Management Association (MGMA) has found that better performing medical practices average just 4% in claims denials in their medical billing. Time and time again, practice and billing managers say they struggle with denials. In her recent webinar about managing denials, Elizabeth Woodcock, said it can cost as much as $15 per denial to follow up. This explains why only 35% of practices appeal denied claims.

Elizabeth says a medical billing staff person should be able to follow up on about 50 items a day and in the MGMA blog they suggested that an experienced biller can work about 500-700 denied claims a month. So it is doable. Your practice can manage denied claims—and according to Elizabeth for a lower cost.

But can you reduce the percentage of denied claims at your practice and avoid many denials all together? Yes! There are many ways to prevent and reduce denials before they happen. The first step is figure out what your denial rate is. In a post on the Kareo Getting Paid blog, Sara Larch provided this formula:

  • A = Total claims filed to a payer (number and total charge amount)
  • B = Number and dollar value (charge) of denied line items
  • C = Calculate percentage denied (B divided by A)

Once you know your percentage of denied claims you can set a realistic goal for reducing that rate. Start by running a report that shows your top ten to twenty denial reasons. Most likely this will include issues like incomplete insurance information (or other missing information), claims that lack enough specificity, claims not filed on time, illegible paper claims (if you have payers who still require paper). As you identify each issue, work on a plan to address that problem and reduce the instance in your practice. For example, if missing information is a problem:

  1. Work with front desk staff on a step-by-step process to ensure that they gather and double check patient information on the phone and in person at each visit.
  2. Have billing staff review the entire claim and look for specific items that are often missing to ensure the information is there and accurate.
  3. Use a billing system that provides claim scrubbing before submission to the clearinghouse and a clearinghouse that provides claim scrubbing when claims are received. This will often catch things that humans can miss.

Create a process like this for each issue and work on improving them one at a time.

Using software that also provides alerts when claims are denied or when a response has not been received for claims within a specified period of time can help your staff to quickly move on problem items. To find out more about Elizabeth Woodcock’s four-step process to more effectively manage these denials, see the slides from her recent webinar.

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ICD-10-CM: 5 Things Physicians Should Know to Prepare

Lea Chatham July 17th, 2013

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By Lisa Eramo

Patient care is a physician’s first priority. However, cashflow keeps your practice’s doors open. This is all the more reason to dive into ICD-10-CM/PCS and begin to learn how it may affect your practice, says Sandra Draper, RHIT, CCS, director of education and development at Precyse, which provides specialty-specific ICD-10-CM/PCS education and documentation audits for practices nationwide.

Draper discusses important differences between ICD-9-CM and ICD-10-CM that physicians should keep in mind to prevent major disruptions in revenue.

[Note: To access the most up-to-date version of ICD-10-CM, visit the Centers for Disease Control and Prevention Web site to download the 2014 ICD-10-CM code set.]

Kareo provides infomration for physicians on ICD-10

  1. Laterality: Unlike ICD-9-CM, ICD-10-CM specifies left, right, and bilateral. For example, a patient presents with a cyst on his or her eyelid. To properly report the ICD-10-CM code for this condition, physicians must document whether the cyst is on the right or left lid. They must also specify upper vs. lower lid.
    What you need to know: Although ICD-10-CM provides an option for ‘unspecified eye,’ payers will likely not accept this code (H02.829) because it provides very little clinical information. Physicians should crosswalk any diagnoses on their superbill from ICD-9-CM to ICD-10-CM to determine whether any of the conditions require laterality. Laterality is a common theme throughout ICD-10-CM, so it’s likely that at least one condition on a superbill will be affected.
  2. Anatomical site or location: ICD-10-CM requires far more detail in terms of the location of an injury or condition. For example, a patient presents with a cerebral infarction due to an embolism. Physicians must document precisely where the embolism occurred, including laterality as well as the specific artery (i.e., in the precerebral artery, carotid artery, basilar artery, vertebral artery, middle cerebral artery, anterior cerebral artery, posterior cerebral artery, or cerebellar artery).
    What you need to know: Physicians should take the time to read through the ICD-10-CM code descriptions pertinent to their specialty to understand what type of clinical detail is required.
  3. Combination codes: ICD-10-CM includes hundreds of combination codes (i.e., codes that link symptoms, manifestations, or complications with a particular diagnosis). For example, ICD-10-CM code I25.10 denotes atherosclerotic heart disease of native coronary artery without angina pectoris. Code I25.11- denotes atherosclerotic heart disease of native coronary artery with angina pectoris. The sixth digit specifies more information about the angina pectoris (e.g., whether it’s unstable or with documented spasm).
    What you need to know: To report combination codes correctly, documentation must clearly indicate the presence of the symptom, manifestation, or complication along with the pertinent condition to which it corresponds. Documentation must also link the two together (e.g., coronary artery disease with unstable angina).
  4. Type of encounter: Some ICD-10-CM codes specify whether the encounter is initial, subsequent, or sequela. For example, a patient presents with a laceration of his or her right hip tendon. Physicians must document the type of encounter so coders can assign the 7th (and final) character in the ICD-10-CM code. An initial encounter is one in which the patient receives initial active treatment. A subsequent encounter is one in which a patient receives routine care during the healing or recovery phase. A sequela encounter is one in which a patient receives treatment for complications or conditions that arise as a direct result of a condition. The 2013 ICD-10-CM Official Guidelines for Coding and Reporting provide examples of each.
    What you need to know: The type of encounter is required for valid submission of certain codes. Those working in the orthopedic specialty should pay close attention to the 7th character, as it may also include other important information, such as the type of healing (i.e., routine, delayed, nonunion, or malunion).
  5. ICD-10-CM coding guidelines: If physicians assign their own codes, they must—at a minimum—read through the 2013 ICD-10-CM Official Guidelines for Coding and Reporting. This document is a treasure trove of information that includes little known facts that about the new coding system physicians could easily overlook. For example, ICD-10-CM requires inclusion of a placeholder character ‘X’ for certain codes to allow for future expansion. Code category T36-T50 (poisoning by, adverse effects of, and underdosing of drugs, medications, and biological substances) is one example.
    What you need to know: ICD-10-CM codes can range in length from three to seven characters, including placeholders. Only complete codes will be considered valid. Review the guidelines for more information about coding conventions and diagnostic reporting for outpatient services.

About the Author

Lisa Eramo Freelance

Lisa A. Eramo (leramo@hotmail.com) is a freelance writer and editor based in Cranston, RI who specializes in healthcare regulatory topics, health information management, and medical coding.

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Will HIPAA Omnibus Complicate Compliance?

Lea Chatham July 15th, 2013

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By Ron Sterling

Ron Sterling explains key aspects of HIPAA Omnibus for Kareo

The HIPAA Omnibus Rules, released in January 2013, will dramatically affect how you manage and deal with the impermissible disclosure and use of Protected Health Information (PHI). Indeed, the new HIPAA Omnibus rules place a burden on your healthcare organization to analyze and document your review of potential PHI breaches. As a practical matter, your healthcare organization could be looking at substantial problems complying with these requirements unless you strengthen your monitoring strategy.

Under the “old” HIPAA/HITECH Breach rules, a breach required a significant risk of financial, reputational, or other harm to the individual. Under the “new” HIPAA Omnibus rules, a breach is based on a much lower standard of PHI disclosure or use that does not have a low probability that the PHI has been compromised. As important, you can now evaluate potential breaches and document your “good faith evaluation” and “reasonable conclusion.” Alternatively, you can just assume that the event is a breach.

The evaluation is based on four factors:

  1. PHI Nature and Extent: You can evaluate the sensitivity of the impermissible disclosure as well as the ability to identify the patient or even the presentation options. For example, a list of dated deidentified lab results disclosed with a separate list of patient appointments for the day of the lab would present a higher probability of impermissible disclosure or use. Similarly, PHI scanned images may include patient identifiers and present a higher probability of disclosure.
  2. Unauthorized Person Received or Used PHI: You must evaluate the recipient of the impermissible disclosure or use to determine the extent of the problem. For example, impermissible disclosure to a party that has been properly trained in HIPAA Privacy and Security who works for a Covered Entity or Business Associate may present a lower probability than the impermissible disclosure of PHI to an employee of your own organization that has not been trained on proper HIPAA Security and Privacy standards.
  3. Actual Acquisition or Viewing of PHI: In evaluating the problem, you can determine if there was an opportunity to access the PHI. For example, a file of information that requires a special reading program presents a lower probability than a patient record in a PDF file. Similarly, if a device was lost, but upon recovery, you can determine that the device was not accessed, you have a low probability of disclosure or use.
  4. Mitigation Factors: In the final step of you evaluation, you can determine if there were mitigating issues that leads you to a good faith and reasonable conclusion that the information was not disclosed. For example, a thumb drive containing PHI on a patient lost in the HCO, but recovered in a nonpublic area may present a mitigating factor. Indeed, you may reasonably rely on the promises of the party to whom the information was improperly disclosed.
The evaluation of these four factors has to be documented as well as your good faith and reasonable conclusion. If you determine that the probability of compromised PHI is low, you do not have a problem. Otherwise, you have a breach and have to respond according to the breach notification requirements.
However, you should seriously consider the implications of the impermissible disclosure and use on your organization. You should:
  • Examine the events that lead to the impermissible disclosure and use in light of your HIPAA Privacy and Security policies and procedures. Indeed, the impermissible disclosure or use should trigger an analysis of the relevant policies, and procedures as well as supervision and training of employees.
  • Track all impermissible disclosures (including breaches) to support analysis of problems that may lead to more serious issues in the future. For example, just because you have not graduated to a breach for a number of impermissible disclosures and uses does not mean that you do not have a weakness. Indeed, continuing PHI disclosure and use problems could be an indication of a potential problem and higher risk profile than your breach log shows.
The updated breach rules in the HIPAA Omnibus Rules lower the barriers for a breach and increase the work that you need to do to track impermissible uses and disclosures of PHI. The analysis of impermissible disclosures and use can help you identify weakness and strengthen your Privacy and Security strategies. Alternatively, a history of impermissible uses and disclosures may unfavorably reflect on your effort to protect PHI even if you have avoided an actual breach.
About Ron Sterling

Ron Sterling discusses strategies for EHR success for Kareo

Ronald Sterling, President of Sterling Solutions, Ltd., is a nationally recognized thought leader on the selection and implementation of electronic health records (EHR). He authored the HIMSS Book of the Year, Keys to EMR/EHR Success: Selecting and Implementing an Electronic Medical Record, and publishes the popular EHR issues blog: Avoid-EHR-Disasters.com. He has worked with a wide array of practices on EHR decisions and issues and has reviewed electronic medical record and practice management systems from over 150 vendors.

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Webinar: Tested Medical Billing Techniques that Get Claims Paid

Lea Chatham July 11th, 2013

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Wednesday, July 17, 2013 1:00 PM EDT/10:00 AM PDT
Speaker: Elizabeth Woodcock

Is this your practice? Denied claims languish for days–even weeks–before a staff member finally resubmits. Then they come back: denied again. You don’t need a complex claims denial-management system, but this work process does require your time and attention. With the cost of reworking a claim approximately $15, and perhaps more, you simply can’t afford stay on the denial merry-go-round.

In this fact-filled webinar, national speaker and practice management consultant Elizabeth Woodcock shows you how to transform your practice’s insurance billing function into a claims resolution machine. If your practice has 5% or more of its claims denied on first submission, then this informative webinar is for you.

Learn Elizabeth’s proven four-step process (Measure-Monitor-Prevent-Work) for getting claims paid. Absorb her proven tips and tested techniques for implementing a claims denial prevention and management program in your practice… one that meets the challenges of today and tomorrow.

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

Who Should Attend Private practice owners, practice managers, billing managers and others concerned about improving medical billing, reducing denials and getting paid.

Elizabeth Woodock discusses medical billing tips to get claims paid

About Your Speaker:

Expert Elizabeth Woodcock will explain best practices for appealing denied claims

Elizabeth Woodcock, MBA, FACMPE, CPC is a professional speaker, trainer and author specializing in medical practice management. She has focused on medical practice operations and revenue cycle management for more than 20 years.

Elizabeth Woodock discusses medical billing tips to get claims paid

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Don’t Miss Great Medical Billing Tips in July Newsletter

Lea Chatham July 10th, 2013

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The July edition of the Getting Paid Newsletter is packed with information about managing denials, evaluating patient satisfaction, connecting with Kareo, and more. The newsletter provides a chance to catch up on some interesting industry news, get medical billing tips, and find out how you could win a gift card for connecting with Kareo on social media channels. You’ll discover more about how to register for our upcomg free educational webinar, also provided by Elizabeth Woodock, on July 17. Read all this and more now!

Medical billing tips from Kareo

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How Important Is Increasing Patient Satisfaction?

Lea Chatham July 8th, 2013

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Kareo survey about patients and patient portals

At his HIMSS 2013 keynote address, Eric Topol, MD said, “The blockbuster drug of the century is an engaged patient.” The more engaged patients are the more satisfied they will be with their care. The more satisfied they are the more engaged they will be in their own care and wellness. It’s the healthcare equivalent of the chicken and the egg. Which came first satisfaction or engagement? And how are you going to make both things happen because patients who care about their health will inevitably be the change makers. They will ultimately determine what the future of healthcare looks like and have a big impact on reducing costs.

The first question for practices is how are you doing now? According to the American Customer Satisfaction Index (ACSI), which measures customer satisfaction in a variety of business sectors, with scores based on a scale of 1 to 100, you aren’t doing too bad. Satisfaction with ambulatory care registered 82%. And this is an improvement of more than 1% over last year. So you’re headed in the right direction.

But you aren’t necessarily there yet. Recently, Consumer Reports asked 1,000 people about their biggest medical gripes. These complaints were rated on scale of 1 to 10, with 1 meaning “you are not bothered at all” and 10 meaning “you are bothered tremendously.” All 16 complaints were rated above a 5 with more than half receiving an average of 7 or higher. The biggest complaints were largely about communication issues:

  • Not receiving a clear enough explanation of a problem
  • Having difficulty resolving billing issues
  • Test results not being communicated fast enough
  • Issues being discussed in earshot of other patients or staff
  • Side effects not being clearly explained

To address communication problems, it is often best for physicians and managers to provide a leadership role and model best practices. Even if you think that you have communicated the problem clearly or provided adequate explanation of the lab results, always ask the patient if he or she understands what you have said. Front desk and billing staff should be instructed to do the same. If someone calls with a billing issue, take the time to hear them out, provide clear explanations, and ask if there are questions or additional concerns.

Whether you choose to attest to Meaningful Use or not, providing printed information for patients and access to a patient portal are equally good ways to address some of these issues as well. The more opportunities patients have to provide more information, review the information you have provided, or submit a query, the better. In a recent survey, Kareo found that 70% of patients said they would be very likely to access their medical records online and 63% of respondents would prefer to receive electronic communications from their physician.

Finally, you might consider a patient survey of your own patients. There is some debate about the efficacy of patient surveys overall, but if you really feel that you need to better understand your patients concerns it may be the best way to find out on a broad enough scale to truly  see the larger issues at hand for your practice.

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Medical Billing Plagued by Denials Based on Registration Errors

Lea Chatham July 8th, 2013

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By far, the most frequent type of denials in medical billing are those that are related to registration. These denials center on the patient’s eligibility for insurance coverage – or, in the case of a denied claim, the lack thereof. If the patient isn’t eligible for the services you render, you can (and perhaps should) bill the patient. That sounds like a great solution until you realize that you aren’t likely to be paid – industry experts reveal that 81 percent of self-pay patient responsibility and 55 percent of all patient financial responsibility end up as bad debt.[1] Thus, before you transfer the invoice to the patient, check all other sources of registration information you can access, such as the hospital’s registration system, and verify every character on the card that you captured at the point of service.

Since some, if not most, registration denials end up as patient bad debt, it pays to make pre-visit eligibility verification an integral part of the registration process. Download your schedule of all patients with upcoming appointments into an automated eligibility system or perform real-time eligibility, available through most practice management systems. If you don’t have access to an automated eligibility process, sort your appointment schedule by payer, and perform individual eligibility checks using each payer’s website. That takes some staff time but the denials you will avoid make it more than worth the effort.

Performing eligibility verification a day or two prior to the patient’s appointment allows time to contact ineligible patients about an alternate insurance. For those patients who no longer carry insurance, you can communicate with them and state your expectations about payment arrangements. At minimum, you can make the request for alternate coverage as the patient checks in for his or her appointment.

If you want to hear more about why claims are denied and learn proven strategies to effectively address denial management, join me on July 17 for the free webinar Denial Management: Tested Techniques that Get Claims Paid.

About the Author

Expert ElizabethWoodcock will explain best practices for appealing denied claimsElizabeth Woodcock, MBA, FACMPE, CPC is a professional speaker, trainer and author specializing in medical billing and practice management. She has focused on medical practice operations and revenue cycle management for more than 20 years. 

[1]McKinsey & Co:  Overhauling the US health care payment system, June 2007; The Advisory Board Company, Financial Leadership Council. 2007. Cultivating the Self-Pay Discipline.


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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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