Mid size independent medical practices have been hit hard by the various trends over the last few years in insurance reimbursement. The overall reduction of Medicare and Medicaid reimbursement, third-party payers negotiating fee-for-service contracts., tightening of claims submission requirements, and the increasing need for patient facing technology portals. During this same time overall business expenses and regulation have increased.
Have strong and consistent revenue cycle management processes are key to success. This begins with sound policies, processes and technology. It also requires accurate projections and reporting. These elements are even more important when industry transitions take place, such as ICD-10.
Revenue cycle management beings with accurate patient data. Haphazard data entry and insurance verification will cost the practice big in the long run. Using a script and following a strict check-in process can ensure even new staff can gather the appropriate information once trained. Front desk policy is so important for supporting your front line staff. They have to deal with challenging patients every day. Being able consistency cite clinic policy, and better yet, point to the sign on the wall about co-pays or other rules is the first step to instituting a consistent front desk experience. Attention to detail in these processes and staff accountability are also important, such as reviewing information provided for accuracy and grading staff on the quality of their check-ins.
Eligibility must be checked prior to appointments. In this day and age most advanced practice management systems can run an eligibility check on the fly or schedule auto eligibility on a weekly or even daily basis. Do not ignore or underestimate the importance of this step in the revenue cycle management process. It will cost on the back end.
In the same vein, services that require referrals or pre-authorization are a huge area for denied claims. This is also the case for work comp claims. Having a check-in process that reviews patient coverage and the associated authorization requirements can reduce the risk of unpaid services. Moreover, having a system that can track service units and flag patients that are nearing their limits will prevent patients from exceeding their authorizations.
Once the patient has been seen another dynamic often occurs. The provider is just too busy to do their notes and enter their charges. Worse yet, a provider simple forgets about an appointment all together and the service is not billed out and timely filing kicks in and the reimbursement is lost. Having a written policy for providers that addresses timeliness for completion of charts and coding. The next step is to perform a regular audit of all appointments and associated charges. A big area for missed appointments is off hours or out of office services, such as weekend surgeries or hospital deliveries. Just identifying 25 missing visits a month at an average of $150 can make a big difference in your practice revenue.
Once you have confidence that you are capturing all the charges then reviewing charting and coding for maximization of reimbursement is the next step to successful RCM. Those responsible for coding should be engaged in regular professional development to stay on top of best practices. Ensuring your practice management system is setup for coding workflow, such as the ability to categorize visit types and integrated coding search tools, will ensure efficient and accurate coding. Clear communication channels between providers and coders is also key to facilitating feedback, getting questions resolved, and improving documentation.
Having a high-end clearinghouse to send your claims is the next element of technology in the RCM process. A quality clearinghouse will provide rejections with actionable detail, the ability to sort and categories rejections and produce reports to see consistent issues. More importantly, a robust clearinghouse will allow edits to continuously fine tune your claims and ensure the correct payer specific modifiers are being added. Having your files sent and received electronically as Electronic Remittance Advice or ERA is absolutely necessary. Lastly, getting your check delivered EFT will create quicker turn-around times and less opportunities for errors.
Once claims have gone out and rejections worked a separate and thorough process of posting payments and working denials begins. Following the steps laid out above will reduce your overall denial volume. Having a organized denial management and follow-up process is a subject for another article.
Managing the revenue cycle in an independent mid-size medical practice is critical to success. Timing and workflow must be incorporated into every step. Running a tight ship will help the practice navigate the negative trends or bumps in the road as they occur. Outsource Receivables is in the business of revenue cycle management so clinics can focus on what they do best – provide care for their patients. Give us a call or fill out the contact form to take the first step and complete ORI’s practice assessment.