When you went to medical school, it probably wasn’t because you’d always dreamed of being an accountant. However, understanding the financial side of healthcare is an essential part of practice management.
We asked reimbursement specialists from three Alabama medical billing firms about the most effective strategies for making sure your claims are paid promptly and correctly.
Verify Up Font.
Patients move, change jobs, get married, maybe divorced. Circumstances change and change affects coverage.
“When patients arrive at the front desk, it’s important to verify whether their insurance has changed, and look for other changes,” said Donna Burns of Physicians Resource Network. “Do they have a new address? Have their deductibles and co-pays changed? Verify and collect the correct amount up front.”
Donna Stariha of MediSYS added, “It’s surprising how many times patients think they have Medicare when they actually have a Medicare HMO. It’s important to look at the card to verify the details of their coverage.”
Gavin Ellis of MediSYS noted another easy-to-overlook omission. “With Blue Cross, you must have the subscriber’s birthday on the claim. Even if it’s for the child of the primary insured person, it has to be there.”
Get Required Referrals and Precertification.
To avoid problems later, one important rule is to make sure all required referrals and precertifications for procedures are in place.
“It’s also important to get the NPI number and group number of referring physicians,” said Judy Campodonico of Management Resource Group.
“If you don’t, your claim won’t be accepted and it won’t be paid.”
Match Codes to Procedures.
“One of the most common reasons claims are rejected is because the diagnosis code doesn’t match the procedure,” said Julie Mobley of Physician’s Resource Network. “A physician might accidentally mark the wrong code or the office staff could keyboard it wrong. It’s important to make sure codes are accurate so the claim isn’t kicked out and delayed.”
“Physicians are more in tune with coding than they were ten years ago,” Stariha said. “More medical schools are beginning to teach it. It can still take a while to make sure you’re coding at the right level.”
Ellis added, “Every year there are updates to the ICDN diagnosis book. It’s important to learn the new codes and use the most specific diagnosis number, which is now to the fifth digit.”
Check Twice, Submit Once.
Little things, as simple as a misspelled name, can result in a rejected claim.
“It’s important to educate the office staff on how much depends on getting it right the first time,” Mobley said. “Making sure information is entered properly can save so much time later.”
Learn about Modifiers.
“There is really nowhere they tell you that you need a modifier. It’s just something you learn by experience,” Campodonico said. “It can make a huge difference in whether a claim is accepted or rejected.
“For example, if a planned surgery was followed by a surgery for complications, the follow-up procedure might be denied without a modifier to indicate it was a second surgery. If a knee injection began with a separate injection of a drug to numb the area, it would be billed as an office visit, two drug codes and two administration codes. Without a modifier to indicate that there are two separate injections, one might be denied.”
File Promptly and Check the Status of Claims.
“Transmit claims daily or as often as possible. Check reports regularly, and if a claim comes back with a zero payment, research it and find out why,” said Jane Wier of MediSYS. “You also need to be aware of check-write days, and be working claims in advance.”
Campodonico seconds that advice.
“Work rejections, get changes in as soon as possible, and do appeals,” she said. “Apply what you learn to future claims. It’s difficult to be on the phone a long time for one claim. In small offices, it’s easy for everything to get pushed aside, so rejected claims often slip through the cracks and payment is lost.”
Check for Undercoding/Overcoding
To avoid the problems that can arise from overcoding, some physicians are prone to undercoding, or simply don’t have a feel for what level of coding the documentation supports.
Some billing services offer medical billing chart auditing for both their regular clients and on a project basis.
“We take a 25-chart sample to check for HIPAA compliance, whether diagnosis codes match procedures, and we look for undercoding or overcoding, and check whether documentation would have supported more or less,” Campodonico said. “You can see how your procedures are working and if you’re audited, it shows that you are working to get your claims right.”
Be Proactive in Learning about Changes.
“Learning on the job through trial and error can be expensive. Many carriers
have seminars and training, plus information on their Web sites. It’s important for your staff to know how to go get information and keep up,” Stariha said.
Campodonico added, “It’s not getting easier. There have been so many rule changes, it is getting difficult to get a claim paid. If someone in house is handling your claims, you need someone dependable who will go get the information. Cross-training is also essential. If a staff member goes out on maternity leave or on vacation, you need other people who know how to do it right.”
If You’re Too Busy to Stay on Top of Claims, Find Someone Who Can.
As a practice grows, it may be worthwhile to look at how much lost claims cost versus what more effective claims handling could bring in by investing in additional staff or outsourcing.
“Some physicians come to us after meeting with their accountant when they realize they aren’t making the money they should be making and how much is getting left on the books,” Burns said. “If you are considering a billing service, some of the things you’ll want to look for are experience and their reputation for past performance and service. Will they work with your staff, and will they be there for you if you need them? During a recent insurance audit of a physician group, we had our compliance person and billing person there, and our clients said it relieved their minds to have us there.”
Ellis added, “With the complexity of billing, it’s hard to recruit staff with the knowledge and experience necessary to be effective. If you outsource, look for a track record and someone who will maintain an open line of communication with key people in the practice. They should be available to discuss your needs and adapt their services to the requirements of your specialty.”
“The number-one thing to look for in a billing service is experience,” Campodonico said. “Our clients are counting on us to know. And it’s important to have a good working relationship with the physician’s office staff. We also have a shared interest. Since we’re paid by a percentage of what we bring in, they know we’re working to bring in the maximum.”
While the maze of reimbursement can be frustrating, healthy cash flow is vital to a medical practice. Whether it’s in-house staff or a service, physicians need effective reimbursement management, so they can concentrate on patients.
May 2008
