It's impossible to chase down every $5 underpayment individually, but when you're being shortchanged repeatedly for a procedure that's common in your practice, you need to identify and address the problem.

"When we know they're all on one payer or one code, we can settle it almost immediately," says McKeough. "And we'll just have someone put together an Excel spreadsheet, providing the dates of service, the [patients'] insurance IDs, how much we were underpaid, and a sum on the bottom with a note saying, 'Mail us a check.'"

You can also run reports on common procedures by all payers, as a way of helping guide decisions about your future relationships with some of them. Be careful to consider the whole picture, though, before dropping any contracts — a seemingly lower-paying contract may actually be a better deal than one with higher allowables, if the lower-payer is timely and hassle-free.

One thing's for sure, says Reynolds: you can't count on the carriers to help you out. A payer isn't going to alert you that you could get more of its money if only you'd make a minor change in your coding practices. It's incumbent on you to know what's coming into your office, and how much effort — and time — it's taking to get it there.
Your time is perhaps the most valuable thing you have, after all. You literally can't afford to waste it — or have it wasted for you.

Speaking of which ...

Challenge: Scheduling

Maybe it's just a sign of the times. What with so many two-income families struggling with super-hectic schedules, suburban traffic jams worse than ever, and the apparent decline in basic civility in American life, it's little wonder people so commonly show up late for appointments — or not at all.

Not that any of those excuses makes life any easier on you. In the modern medical practice, it's tough enough to make ends meet when everything goes smoothly; you can't afford to waste appointment slots. It costs your practice money, makes it harder for you to stay on schedule, and exacerbates patient wait times.

A few years ago, practices like Potomac Physicians could grudgingly tolerate the no-show problem. It was annoying, says Reynolds, but because so many of the practice's contracts were capitated, it didn't matter very much if a patient blew off an appointment, as long as the patient rescheduled.

"You were getting that capitation money, anyway, so you could afford to see Mrs. Jones at another time," says Reynolds.

No longer. With capitation just about dead as a reimbursement model, Potomac Physicians had to find a way to reduce if not eliminate its no-shows, and to minimize their impact on its operations. Its answer: open-access scheduling. Two years ago the practice scrapped its old system of requiring patients to call days or weeks in advance for appointments, and instead committed itself to seeing most patients the day they call.

"As we like to say, we give them what they want when they want it," says Reynolds. "It's all about service, and that's the only way to make the business run."

It wasn't an easy transition; getting the group's physicians to buy in to a radically different scheduling system was a tough sell. But it's been worth it.

"Often we had to make our schedule go longer than the doctors expected, or add patients on where other patients were, and ask doctors to apologize when patients had to wait, but to work through it," Reynolds explains. "And since we've done that, we've been able to get to the point where 65 percent to 70 percent of our appointments are same-day, our schedules are full, and the no-show rate is probably 2 percent or less. And that was quite an incredible feat."

Best of all, she says, patients love it; when people are sick, it doesn't do them much good to get an appointment for two weeks later. Potomac Physicians "could never go back" to its old scheduling system because patients have come to expect same-day access, she says.

But not every practice situation is appropriate for same-day access, and some aren't ready for, or interested in, making the switch. In those cases, Woodcock suggests you consider the following possibilities:

• Appointment reminder calls and patient call-backs. Many practices use reminder calls as a way of reducing no-shows. Yet some are still plagued by the problem, as patients tend to ignore or forget about the reminder messages left on their answering machines. Some groups are now requiring patients to call the practice back to confirm the appointment. If the patient doesn't call back, the appointment is canceled. "Practices that do this usually restrict it to a subset of important visits, like expensive procedures and new patients," says Woodcock. "If you implement this policy, remember to inform patients in writing before you start, and be sure you can handle the extra phone calls."
• Charging patients. Should you charge patients a fee for blowing off an appointment? It's worth considering - more groups are charging fees that typically range from $15 to $25, Woodcock says, and the practice is "getting patients to pay attention." But consider the time and money it will take to collect the fees versus the benefit you'll get. "Don't even try this if your practice serves an indigent population or some other hard-to-reach patients," she warns. And if you go forward, explain it to patients in writing in advance, post signs, and have your scheduler remind patients about the fee when they make appointments. Often, the patients who forget to keep their appointments are busy professionals — and well-insured. Don't drive them from your practice just to fill your schedule with compliant, but lower-paying, patients. "Remember," Woodcock says, "the point is to get patients to keep their appointments, not to boost revenue $15 at a time or drive patients away."
• Setting appointments when needed. Annual appointments are common in many specialties, but trying to schedule an appointment a year in advance is a great way to increase no-shows. Instead, remind patients six weeks or so in advance of their due date, and set the appointment when the patient calls in.
• Pre-appointment screening. Subspecialists with a narrow field of clinical care often find that many inappropriate patients are referred to them. If you're in this boat, consider a pre-screening system. But be careful not to make it too cumbersome or time-consuming; patients should know the day they call whether they'll be able to make an appointment, and referring physicians should be educated on precisely the clinical issues you're prepared to handle — and those you aren't.

Challenge: Too much paper