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What Tooth Decay and Securing Your Medical Practice Revenue Have in Common – Part 3


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

In Part 1 and Part 2 of this series, we discussed:happy physician

  1. Managing Your Contracts
  2. Capturing Your Work
  3. Clinical Coding Accuracy
  4. Accurate and Thorough Claim Submission
  5. Identifying Payors Underpaying Claims

The remaining elements required to legitimately maximize your revenue, involve how effective your billing process and people are in responding to the nuances and disruptions in the billing work flow as well as the attention paid to review or audit the entire process as a whole.

Rapid and Attentive Response to Inquiries

Once initial claims have been filed and/or initial statements for self-pay patients have been sent, anywhere from 25% to 30% or so of your money can still be outstanding. Inquiries from payors and patients come in many forms; electronic remittances and responses, phone calls, emails, and faxes.

The speed and competence with which your billing process staff respond to each of these inquiries has a profound impact on your bottom line. In addition to accelerating payments that only require a step or two to resolve, addressing inquiries timely provides the billing process with information it lacks to resolve a claim.

Failure to respond to inquiries promptly has many adverse consequences. In addition to delayed or lost revenue, billing statements sent to your patients that do not reflect the changes they’ve already communicated to you can infuriate them. Some of these patients are likely to contact the facilities you serve, creating needless negative impressions of your professional practice.

 

Responding Timely and Effectively to Denied Claims

Payors sometimes deny claims for legitimate reasons. But based on our recovery of revenue on “just” denied claims, it is clear that payors often deny claims that are legitimately payable on the first submission of the claim.

So if your billing process is not strong, you are getting the compound effect of claims that payors will deny in addition to inaccuracies or other errors that are systemic within the billing process.

It is vital to respond timely and assertively to denied claims and require payors to fulfill their obligations to you.

Because responding to denied claims is so time intensive, it is one of the areas that billing companies or in-house billing processes either can’t or don’t allocate time to. Since billing companies are generally paid on a percentage basis, they may not be as motivated to invest the additional resources to protect your interests. In the case of in-house billing operations, the denials are hard work and may fall to bottom of the stack of the to-do list and be neglected, not by intent, but lack of efficiency and/or resources.

 

Auditing the Entire Billing Workflow

Billing best practices include applying tools and metrics that assure all the details of the billing process are validated and well managed. Because of the complexity and volume of billing, each individual process needs special attention.

But beyond this, it is essential to take a step back and periodically evaluate the process as a whole and discern if there are any obvious, big picture elements that are being overlooked.

One simple yet effective way to take a first step in this direction is to select a specific number of procedures, say 50 to 100, and follow them from your EHR (or other transcription or HIS system) through the entire billing process. Almost every billing system has the ability to extract and print the claim history including the patient information, date of service, date the claim was filed, and every event that occurred through the resolution of the claim.

By doing this at a micro level, you will be able to validate accurate CPT and ICD-10 coding of procedures, timeliness of the claim being filed, response of payor(s), accuracy of payment, and follow-up by billing staff.

 

In Summary

You do not need to be uncertain about whether your billing process is efficient and maximizing the revenue you’re entitled to.

Peace of mind comes with knowing.



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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