What Tooth Decay and Securing Your Medical Practice Revenue Have in Common – Part 1

Except for enamel, teeth are comprised of living tissue with cells that can repair themselves. Only the enamel is made of non-living cells. The enamel protects the living cells but can fail to secure the teeth if appropriate attention and maintenance are not provided, resulting in decay. There are multiple stages of tooth decay.

  1.  Spots appear on the tooth as a white or yellow chalky substance
  2.  Enamel begins to break down
  3.  The level below the enamel, dentin begins to decay
  4.  The pulp below the dentin is infected
  5.  A painful abscess forms requiring immediate medical attention

The early warning signs are hardly noticeable. But the adverse impact of untreated decay has an accelerating and parabolic impact. Your 28 teeth (on average) represent a coordinated system that helps you chew and begin the digestive process to maintain your health each day.

Much in the same way, small irregularities in your medical billing process can occur with minimal consequences at first, which if left unchecked, can balloon into extraordinary amounts of lost revenue.

Your billing system has many potential points of failure (cavities). Diagnosing them can be challenging unless business is your forte and process management is your passion. If your teeth aren’t on a regular maintenance program, cavities and absences can form, eventually causing extreme pain and requiring root canals or extraction. If your billing process isn’t developed, managed and monitored effectively, the amount of money that can be lost is staggering.

To identify the points of failure is the first step of restoring your income. The problem is, you don’t always know where to look or how to take corrective measures.

Here’s the good news.

You have the opportunity to recover lost revenue. If… you’re willing to acknowledge the early warning signs and take action to remedy the situation.

Many times you have a gnawing sense that money is being lost, but you’re not sure how to get your arms around finding out if your concerns are warranted or not.

In this 3-part blog series, we will provide you with the specific fail points in the billing process where we have helped numerous physician clients recover literally millions of dollars.

Part 1 – Securing Your Revenue – The Foundation

There are three essential elements to establishing a strong foundation in the billing process.

  1. Managing Your Payor Contracts

The claims you are about to file require a relationship with your patients’ payors. (Insurance companies, Medicare, Medicaid, Etc.)

There was a time when signing up with payors was simple, straightforward, limited in scope and once established, required little maintenance. Today’s application forms are complex, intrusive and require a level of preparer sophistication.

Payor contracts cover extraordinarily broad issues and the rate you are paid is only one piece of several key components required to assure strong receipts.


  1. Capturing Your Work

It’s astounding as to how many times we continue to see billing processes that aren’t validating the fact that every exam you interpreted is captured and processed in the billing system.

Hospital computer systems are complex and programmatic changes and updates perpetually disrupt the transfer of your interpretation and demographic data flow to your billing process.

If your current process cannot factually confirm the successful transfer of all your procedures, I guarantee you are losing a substantial amount of money. That means zero dollars for the hard work you’ve already performed. (It no longer surprises us to see us recover 5% to 15% of recovered revenue from this one attribute alone.)


  1. Clinical Coding Accuracy

As your work is translated into CPT codes, and why it was medically necessary translated into ICD-10 codes (which has become extraordinarily complex as of 10/2/2015), there are multiple ways losses in your revenue can occur.

CPT codes can fail to capture the extent of an exam that was performed or the entirety of all exams performed.

If the ICD-10 codes applied do not correlate to the studies performed, the claim may be denied. If the codes are inaccurate, you can not only be subject to non-payment, but penalties for inappropriately filed claims.

As a minimum requirement, you need certified coders applying these codes. There needs to be a peer review process in place as part of a more comprehensive quality review program. Without these, you are both losing money and increasing your compliance risks.

Stay tuned for Parts 2 and 3 of this series:

Part 2 – Securing Your Revenue – Filing and Managing Claims

Part 3 – Securing Your Revenue – Responding to Patients, Denials, and Process Disruptions

While our primary purpose and mission is revenue cycle management, our leaders have decades of physician practice management experience. Call for a free consultation, for up to 1 hour with either John Stiles, Brendala Anspaugh or Don Rodden. We will gladly sign any reasonable confidentiality agreement and dialogue with you further about how you can lead your group in a transformative direction.

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