The road to compensation is a passage paved with convolution. Nevertheless, physicians and their practices are required to travel down that long arduous road every time a new patient walks through the door. With so many miles to trek in a day and a slim window by which to complete the journey, private practice managers need to know how to avoid detours and other general hiccups in the highway without causing too much ware-and-tear to their practice functionality or revenue cycle.
As a means to aid her fellow travelers, Deborah Walker Keegan, PhD, FACMPE, president of Medical Practice Dimensions Inc., relayed a series of dips physicians should watch for in her webinar address “Potholes in the Road to Getting Paid.”
During the sixth segment in a series of webinars dealing with physician practices produced by medical claims clearinghouse Navicure, Keegan outlined the necessary processes required to maintain a successful practice in the face of an ever-changing revenue cycle system.
“Today’s revenue cycle is indeed getting more complex,” Keegan said. “We are changing our health plans to high-deductible health plans and lifestyle plans so we need to maintain a currency in those changes. We also are needing to use our practice management system for steps beyond submitting claims. And we’re adding the incentives and penalties associated with the prescribing, the physician quality reporting system and the meaningful use requirements of the EHR. We also have value-based purchasing, with a number of payers approaching physician practices and wanting to set up at-risk reimbursement and additive reimbursement if certain quality indices can be met.”
All of these alterations, Keegan noted, are occurring “in the midst of a massive experiment in the United States for payment reform,” making an already rocky landscape more grueling.
Below is Keegan’s suggested reimbursement roadmap and a possible contribution to your practice’s revenue cycle salvation.
1) Front-end billing
The modern patient can be characterized as either having money, not having money, or possessing a high-deductible plan. The latter option, Keegan confirmed, is the classification changing the ways in which practices perform front-end billing.
“The high-deductible plan today in some markets is up to $25,000. More typically, it’s between $5-10,000. What we want to do is make sure we understand these new plans and if our contracts permit, we can collect that money from the point of care. We want to be, in terms of a medical practice, right at the forefront of making sure we collect the patient out-of-pocket responsibility at the point of care to the extent that we can if our contracts permit.”
With patient responsibility as a percent of total revenue up 30 percent in 2012 because of these high-deductible, consumer-directed healthcare plans, attributing patient out-of-pocket payments as a key derision for practice revenue streams is a well-founded assertion, according to Keegan. Financial clearance must be conducted on behalf of these plans also, a process Keegan segregated into three steps: verifying insurance coverage, confirming benefits eligibility and assessing financial responsibility.
2) Charge capture and entry
“You need to make sure your capturing all your charges. You need to compare your charges to your source documents and hospital reports,” Keegan said.
Integral stages to be followed in this second arena:
- Develop a “closed-loop” process.
- Standardize charge capture.
- Audit coding/charges prior to “send.”
- Use scrubbing software.
- Work pre-adjudication claim edits; identify root cause and take action.
- Routinely review accounts “on hold.”
- Focus on a “clean claim” – doing the work right the first time.
3) Payment posting
Adjustments can be broken down into two primary categories: contractural and non-contractural. “Don’t just have a column that just says adjustments,” Keegan emphasized. “You want to identify the root cause, you want to prevent the non-contracturals (where outstanding dollars for your practice are) from occurring.”
Staff audits (both quarterly for all staff and every three months for new staff), evaluations of time to payment (self-pay, hospital, payer), “bad debt” assessments as well as collection agency appraisal are all effective measures physician practice managers should take when posting payments.
4) Account follow-up
Insurance follow-ups should be prioritized on the basis of open claims, cost and time, and work accounts should be founded on payer timelines. Keegan also expressed a need for certainty when working insurance correspondences and validating outstanding accounts receivable by dollar and volume by payer. Regarding denial management, it is important that a worthy tracking process is inducted and a reasoning evaluation is in place.
When making appeals, Keegan offered these steps for success:
- Gather objective evidence.
- Access supporting documents.
- Use standard appeal letters.
- Involve the patient.
- Follow up.
- Implement a feedback loop.
5) Patient collections
When designing a statement to collect payment from a patient, it is important to follow these do’s and don’ts of the trade:
- Don’t write “due in 30 days.”
- Don’t print a blank box next to “amount enclosed.”
- Don’t print aging boxes.
- Don’t wait for patient alpha cycle.
- Do develop online statements.
- Evaluate finance charges for late payment.
Keegan spoke of implementing different technologies, like online bill payment options, and methods as to make payment painless for both the physician and the patient. In an ideal practice, the patient payment process should require two statements, no phone calls and one letter, with a completion ratio of 75 days.