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What Tooth Decay and Securing Your Medical Practice Revenue Have in Common – Part 2

Securing Your Revenue – Filing and Managing Claims

In Part 1 of this series, we discussed the importance of:

  • Managing Your Contracts
  • Capturing Your Work
  • Clinical Coding Accuracy

The next steps in securing your revenue emphasize the value in effective process management and confirming your payors are paying what they should be according to their contractual obligations.

 

Accurate and Thorough Claim Submission

In addition to the importance of accurate CPT and ICD-10 coding, there are other issues critical to receiving an immediate and positive response from payors. The next steps in securing your revenue emphasize the value in effective process management and confirming your payors are paying what they should be according to their contractual obligations.medical practice report

The timeliness of filing claims is essential to your strong and stable cash flow. There is a direct correlation between total dollars collected and the promptness of filing an original claim.

When a billing process takes weeks (or months) to file claims, irregularities are compounded, and patients receive statements after payors have paid which is long after the date you served them. The longer the gap in time, the less likely they are to respond.

Equally important is the accuracy and integrity of information accompanying the filing of electronic claims. Failing to assure the accuracy of the correct payor and the correct division or geographic location of that payor disrupts the reimbursement process.

Many payors have adjusted their contracts to only allow a short window of opportunity to submit claims. Many as short as only 90 days. If the initial claim is not filed timely, the payor has a contractual right to deny the claim and you have no recourse. This applies to secondary claims as well.

 

Identifying Payors Underpaying Claims

Payors are contractually obligated to pay you specific amounts per your agreed upon payment schedule. Is a process in place to assure they are complying?

We are perpetually identifying payors who are not complying with their obligations. Some are likely due to system errors at the payor. Some may even be intentional. We don’t know. The important thing is to build and maintain a multi-step process to confirm payor compliance.

This includes tests at the point of their first response to the claim along with systematic monthly and other periodic lookback tests for confirmation. Without these steps, you are virtually guaranteed to be losing thousands of dollars…monthly.

As an aside, though not part of the billing workflow, but as a result of data that can be mined from your billing process, it is important to know if payors are paying you reasonable amounts for your procedures. Knowing what you are receiving per RVU from each individual payor will give you clear guidance on negotiating fair rates of reimbursement.  For more on this, click here.

Very shortly, we will be posting part 3 of this series:

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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