If denials happen anyway, staff at revenue-cycle management companies study what caused them and try to put preventive measures into their databases. “When an LMRP, for example, gets kicked back, we not only say that it is denied and why, but provide a link to the policy. It’s two clicks away from the source,” says Denny.
Most use an application service provider model, meaning clients use the products online instead of buying software that gets installed on a server in the physician office. The Web-based approach means the software stays up to date. Indeed, many vendors update their knowledge base of payer rules on a weekly or even daily basis, gathering data from tens of thousands of physician offices.
Athenahealth, whose products include many aspects of revenue-cycle management, is an extreme example of the kind of research embedded in this type of software. “We are students of payers,” says Kim LaFontana, vice president of operations for the Massachusetts-based company. “We have about a dozen analytical people who study denials and bulletins and payment processes. We write about 100 new rules a week, and they go live immediately. … In fact, we often know more about how a payer pays claims than the payers do.” Imagine your staff duplicating that by trying to memorize every flier that comes through the door — while still sending out claims and calling on late accounts. That’s unlikely to happen thoroughly in a manual system. There is simply too much to master, and it changes too fast.
Many revenue-cycle management tools also help practices understand where to focus staff and what needs to change through the coding and billing cycle to improve revenue. Navicure, for example, allows practices to generate reports pointing out where they are underperforming.
The goals: Better productivity for your billing staff and fewer days in accounts receivable.
Donna Knapper, who runs DRK Billing Specialists, based in Phoenix, used AdvancedMD, another revenue-cycle management company, to fix billing problems for her client, Arizona Back Institute. When Knapper arrived, Medicare owed the practice more than $825,000. Using the revenue-cycle management program, she brought that number down to just $3,000 in 30 days with 100 percent allowable payment.
“The practice couldn’t get any claims for Medicare paid and couldn’t figure out why,” Knapper says. “I saw that claims were being resubmitted over and over. They were mostly being denied because they were missing a modifier, but when staff called Medicare, Medicare just said, ‘The claim is missing something,’ and staff didn’t know what. They don’t know where to find answers and fix the problem.”
The revenue-cycle management tool helped them identify the problem quickly.
Knapper also likes knowing if a claim needs a correction when she submits it, rather than waiting 60 or 90 days to get a denial. She looks for alerts immediately. If a claim is just missing an ID number, she explains, you don’t want staff spinning their wheels trying to figure out what’s wrong with the coding.
Of course, even the best database can’t catch everything. Jayne Lavariere, chief coder for 25-provider, multispecialty Williamstown (Mass.) Medical Associates, likes her product from athenahealth, but found that her version didn’t alert staff when one common procedure — a breast biopsy followed by a mastectomy — needed a modifier. She’d have to run a report to find them.
That’s better than getting denial after denial and not knowing why, and Lavariere says other versions of the product would have alerted her. Still, she says, it’s important to realize that rules can’t capture everything. “You are always more or less a detective trying to find out [whether] the patient [was] here, did they have the surgery, and was the claim filled out correctly? You still need someone to watch over things who has a vested interest in the group.”
Sharp uses a claims cleaning product along with her encoder for ideal results, a combination Navicure’s Denny recommends: “Something reference-based will help guide the biller to a code. We don’t do that. But I can’t imagine why someone wouldn’t benefit. Once you’ve determined what the code is, that is where we come into play. My recommendation would be to do both.”
“We use ClaimsManager [a scrubbing system from Ingenix] as a double-check,” Sharp says. “It’s a hard stop in the charge-entry process, alerting a person during charge-entry that they need a modifier and offering a list. Of course, the operator has to have some coding knowledge to pick the right one.”
For a more complete list of revenue-cycle management vendors, visit the Physicians Practice Buyers Guide.