3 Crucial Steps to Maximize Your Reimbursements

Many of you were busy enjoying the festivities of the holiday season at the end of last year and welcomed the New Year with excitement.  By now you likely have felt the impact of the next season in your wallet.  ReimbursementsI affectionately refer to it as Deductible Season.  Many years ago, this meant there were Part B Medicare patients that may not be able to pay their $200 deductible or for those that were unlucky and had a High Deductible Health Plan (HDHP), it may have meant they needed a payment plan.  Unfortunately for the physician and the patient, many folks are now insured with HDHP’s.  This is not only difficult for the patient, but also for the physician.  It is even more challenging when, you, as the physician don’t even see the patient.

When your specialty is non-patient facing, such as Radiology or Pathology, it makes it especially challenging to collect from your patients.  Before you even attempt to collect from the patient, let’s make sure your billing department is doing everything possible to maximize your reimbursements outside of patient deductibles.  There are three crucial steps in the billing process that are often missed.  Let’s take a look at those and see how your billing department measures up.

Step 1 – Confirm all reports are actually billed

You spend time providing a service to each patient and you should expect to be paid for each finalized report.  Do you know if the work you performed on every patient was actually billed?  If not, you could be losing out on revenue that belongs in your pocket.  Each report should have a unique identifier assigned beyond the patient name and date of birth.  This unique identifier, such as an MRN or Accession #, allows for tracking of every report.  Your facility should provide an independent audit source that can be utilized to validate each finalized report has been entered and billed by your billing department.  Any reports not accounted for should be researched to determine why they have not been billed, bill them if appropriate, and resolve the issue that prevented them from being billed originally.

Step 2 – Validate payor reimbursements are accurate

Believe it or not, payors do actually pay claims.  While they miss some of them for reasons we may never truly understand, there are steps you should take before you start to celebrate that you received payment.  Each time an insurance pays a claim, validation needs to occur to ensure every CPT is paid at your contracted rate with that payor.   At the beginning of your contract year, which may be a calendar year or may not, it is wise to pay special attention to check fee schedules were loaded correctly by the payor and they aren’t short changing you.  A few cents, quarter or even a half-dollar can add up significantly over the course of a year on a high-volume CPT.  After the payment from the payor has been posted by line item to the billing system, a validation needs to occur to ensure the payor contracted rate has been paid accurately according to your current negotiated rate.  If errors are identified, additional steps must be taken to obtain the correct reimbursement, have the payor correct their payment rate and monitoring must continue to identify any future errors.

Step 3 – Analyze your denied and ignored claims

The best process for legitimately maximizing your reimbursements is to ensure you are paid for every claim submitted.  The two most common types of claims that aren’t paid are those that are denied or completely ignored and forgotten about.  It is not uncommon for 20% or more of your claims to fall into these two categories.  When a claim is denied the payor should provide you a specific reason for the denial.  This denial needs to be reviewed by a Subject Matter Expert to determine if the denial is valid, additional documentation is needed, or if there is some other issue with the processing of the claim.  Once the issue is identified, if appropriate, an appeal is submitted for re-processing of the claim and payment expected.

Additionally, in our electronic age of sending 837 files which is also referred to as an Electronic Claims Submission (ECS) file, it is not uncommon for a claim to fall through the cracks.  While the claim is trackable, it may be ignored, routed incorrectly or an entire host of other reasons why it didn’t make it to the processing queue.  For these claims, one must be diligent and follow up swiftly to ensure they are processed accurately before you miss the timely filing window.

In conclusion

How did you measure up?  Were all of these in place and each box checked off?  If you are unsure if these processes are in place, check with your billing department and ask for the last three months of reports that track each area which should include the additional revenue they have recovered from their actions.  These steps alone will not solve all of your billing challenges.  However, developing a plan and process, including validation, to ensure these three steps are performed accurately and timely will head you towards the correct path to maximize your reimbursements.

Once you implement these steps allowing you to maximize your reimbursements from payors, then we can start addressing best practices for the HDHP and how to work collectively with your facilities and patients to increase your patient reimbursement and reduce your bad debt.

Not sure if any of these steps are successfully implemented in your billing department, contact us for assistance on how to implement checks and balances to validate the process.

Sara Nofziger-Drew, Client Relations Director 

Ph 419-223-2785


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