Ten Commandments for Successful Medical Billing operations:
No one disputes that health-care billing continues to face difficult times. Reimbursements are down, costs continue to rise. And while there are multiple solutions to the rising costs in health-care; one fact remains sure, physician practices must meet today's challenges with strategies designed to provide excellent patient care while following often complex and confusing rules.
Practices are under constant pressure to deliver more with less and do it in a way that also incorporates electronic solutions requiring them to spend more to comply. That may means adding EHR software to their already taxed systems. With the looming deadline of 5010 compliance and the roll out of ICD 10, practices can become distracted from the billing process and lose focus on the one thing that can keep them solvent.
Today more than ever, medical billing must receive constant and on-going attention to the right details. Practices have to become more productive and that productivity must be followed by "best in class" processes to be properly paid for those efforts.
Following are some of the best steps to successful Medical Billing functionality:
Step 1: PROVIDER CREDENTIALING/CONTRACTING:
By working closely with a provider representative; fair and proper reimbursement from carriers can be achieved. Once that contract is in place, the practice needs a method to monitor on an on-going basis that the payment agreements are being met. At the same time, close attention needs to be paid to provider enrollment and credentialing. Failure to follow time sensitive rules and carrier requirements can cost the practice thousands of dollars. Accountability for this process must be placed in detail orientated hands. The purchase of soft-ware for larger practices can aid the practice in tracking and full-filling requirements.
Step 2: INSURANCE VERIFICATION AND CAPTURE:
Interaction with the front end personnel of the practice is a critical step in this process. They must understand the role they play in ensuring that provider productivity is paid appropriately and without delay. Capturing copies of insurance and identification data is an essential part of entering correct data into the practice management system. Scanning products can reduce key-stroke errors that are costly. Preventing eligibility denials must be the focus of the front end personnel. They must also verify coverage and benefits PRIOR to the appointment, thus allowing them to collect co-pays and deductibles at time of visit. This includes secondary as well as primary insurances. Updating of practice management system with new or changed information must happen before charges go into system will ensure that changes in benefits or economic issues (i.e. layoffs, unemployment) are captured appropriately. Verification is a step the practice cannot afford to skip.
Step 3: CONTINUOUS EDUCATION OF STAFF:
Continuing education on insurance and coding issues for all the practice staff allows everyone to stay current with the ever changing healthcare industry. As Medicare (MCR) and Medicaid (MCD) offers new options to patients; knowing where to look on card for these changes is critical. This knowledge will help the staff make correct decisions and physicians comply with coding and charting rules. The front-end must comply with appropriate verification with each visit. A mechanism to educate and offer feed-back to the front-end must be in place.
Step 4: CHARGE CAPTURE:
After the visit/procedure/surgery, an encounter form documenting the charge must be entered into the practice management system in a timely and efficient manner. By complying with clear and standard internal rules practices will meet any time filing limits set by various insurance carriers. At the same time, there needs to in place a method that the staff can ensure that every visit/procedure/surgery has been captured. It is not acceptable to the provider that a service performed has not been billed.
Step 5: CLAIM SCRUBBING:
"Scrubbing" (i.e. ensuring all carrier rules for payment have been followed) is a critical step that can make a huge difference in the reduction of denied claims. Ideally, this needs to be performed prior to or at the time of charge entry to the practice management system. This allows the practice to make corrections to the charge that would have resulted in a denied claim. This saves valuable re-work of claim later that typically accounts for the single most costly event of the billing process. Many practice management systems have the ability to scrub a claim or a practice can purchase a standalone product that can be integrated into the practice management system. This investment pays for itself in saved time and paid claims. The job of continuously updating the claim scrubbing tool must also be maintained. New rules must be put into this product immediately. This means that someone must be accountable for this product and the constantly changing carrier rules. A practice should also have the ability to write internal rules into the scrubber to ensure all required fields are appropriately populated.
Step 6: CLEARING HOUSE/ELECTRONIC FILING:
After the charge has been "scrubbed" and is eligible for first time payment, electronic filing of claim through a clearing house should be scheduled multiple times during the week. This process ensures claims reach the carrier faster. The clearing house typically supplies the practice reports that must be checked to ensure all claims went to the carrier. Claims that did not pass clearing house rules must be addressed immediately for timely payment of claim. Electronic filing can also provide the ability of a practice to know that a claim has reached the carrier.
Step 7: PAYMENT/DENIAL POSTING:
As the explanation of benefits (EOB) and payments come back from insurance carriers, prompt posting into the practice management system is the next crucial step in the successful billing process. As with electronic filing, electronic remittance can contribute to the successful billing process with accurate and prompt posting of monies received. From prompt posting, claims can be followed up, secondary claims filed or patient balance billed.
Step 8: FOLLOW UP OF DENIED CLAIMS:
Knowledge of how your practice management system handles various scenarios in the life of a claim is critical knowledge. Often times, options that may help a practice automate this process are not turned on and used which results in manual effort and
over-looked denied claims. A thorough knowledge of the practice system and the various options presented must be an on-going process. Someone must "own" the system and continuously communicate to the management enhancements that may make this process more efficient and cost effective. Having the ability to know which claims are outstanding will allow for quick and easy follow-up with the insurance carrier. The ability to produce workable reports for the staff is critical in staying on top of outstanding accounts receivables, thus reducing the aging of accounts. The process for who and when follow-up tasks are performed must be clear. This process should be monitored (preferably by the system) to ensure the billing office staff is meeting the expectations of the practice. A common denial by carriers is the need for additional information (i.e. documentation). By identifying what codes will be denied for this reason and having a process to have easy access to this documentation allows the staff to promptly send this needed information back to the carrier for prompt payment.
Step 9: OTHER PRACTICE MANAGEMENT REPORTS:
The working of other practice management reports can help the practice to keep accounts receivable clean and accurate. (1) Under-payments by carriers. This report must be worked on a consistent basis to ensure the practice is being paid according to contract. Appeal for additional payment should me made immediately upon detection.
(2) Credit- balances. Many times, posting and other errors are made to accounts that result in a credit balance to the account. These errors must be corrected in order to move accounts to a final status within the system. A clear and timely process to deal with true credit balances must be followed by staff. (3) Small balance write offs. By clean-up of these balances, using well thought out parameters by management, aging can be prevented and cost of statements can be curbed.
Step 10: ACCURATE PATIENT BILLING:
Nothing destroys customer (patient) satisfaction more than an inaccurate and difficult to read statement from the practice. Statements need to be sent to patients on a regular basis to keep them informed of the actions taking place on their account. Accuracy on the statement allows for payment of the balance that is now patient responsibility and reduces calls to the practice for explanation of that statement.
CONCLUSION:
The practice must have good reporting tools to allow the practice to monitor the success of the efforts being made. By analyzing the progress of the practice and making appropriate changes based on findings, the practice can stay ahead of the billing curve. Often, practice management systems have standard billing reports that do not meet the practice needs for proper analysis. By incorporating reporting tools with the practice management database, well-timed and ongoing analysis of accounts receivable can be achieved. Reports must serve a variety of purposes: working reports for staff, summary reports (with trending data) at month end, and financial reports for accounting. Being able to meet all these reporting requirements must be a strong goal of the practice. The medical billing process is complicated; but following these above 10 steps consistently will lead to a very successful outcome for the practice. This process must involve everyone from the patient to the physician. When everyone understands the expectations, success will be shared by all. As rules continue to change, and the road to success gets murkier, processes to deal with these changes and adapt will guarantee a successful practice.
It’s imperative for a practice to see seamless cash flow like how blood flow is important to our nervous system. Its all in the hands of billing team's performance and contribution that matters as a collective achievement as there is say that only if you perform you can take the provider to Penthouse else its the other way around taking providers to the Platform because bad performance.
Always give the best possible in the job you do and leave your foot prints.
