Tom Romeo

When it comes to the financial health of your practice, nothing has a greater impact than the people behind your billing. Whether in-house or outsourced, you need a team you can trust - and one with the experience to do the job right.

A recent Quest Diagnostics survey of more than 300 private practice owners, co-owners and partners provides insight into the greatest pain points related to physician billing.  A closer look reveals opportunities for practices to potentially improve the financial health of their businesses while reducing the time spent handling claims, coding and educating staff about the evolving reimbursement landscape.

The varying requirements from payers pose a continuous challenge to physicians who find themselves facing tighter time constraints and declining reimbursements. It can be difficult to stay current with payer contracts, payment schedules and changing rates for commonly used codes.

Just knowing the correct nomenclature is yet another challenge, and the 

 (ICD) is a prime example. The move from ICD-9 to ICD-10 in fiscal year 2017 brought us from 

approximately 13,000 codes to more than 87,000

. Navigating that many procedures and entries has proven daunting for many providers and their staff.

Many offices have a receptionist, an office manager and a medical assistant. When it comes to keeping up with billing and reworking claims, however, physicians reported in the Quest survey that it’s difficult for this limited staff to maintain the focus necessary, as they simply have too many other demands in a busy office.  Frequently, the available employees lack the necessary experience and expertise to manage accurate and efficient billing procedures.

Adding appropriate technology to your practice can have profound effects on the well-being of your operations, allowing your workforce to focus on what they do best while you concentrate on patient care.

Increasingly, clinicians are adding practice management (PM) software that can reduce administrative tasks, such as scheduling and appointment reminders. Others are outsourcing the billing process altogether. Many practices are exploring 

 (RCM) providers, seeing it as an ounce of prevention for common revenue problems reported by those struggling with in-house billing.

Practices that perform in-house billing can benefit from properly integrated PM software to maintain patient communications while manually handling many billing procedures. It is imperative that someone responds to 

 in a timely manner and that person also stay on top of regulatory changes.

A comprehensive RCM solution removes much of that burden from your team and may make for more timely reimbursements. These tasks would be handled by a service for a percentage of collections or for a subscription fee.

An RCM provider can also handle patient payment collection and claim reviews from insurance companies - common tasks within the revenue cycle - that can be a challenge for many practices. In fact, an enhanced RCM can help avoid issues before they occur. When these functions are properly combined with an electronic health record (EHR) or PM software, physicians can be alerted to potential issues, with the system flagging possible coding errors while still in the exam room.

Should you decide to outsource your billing, consider an RCM that offers these key features:

Management of denials, rejections and appeals

Printing, mailing and emailing of patient statements

Convenient methods of accepting patient payments such as credit cards, online, or customized payment plans

Automated updating of fee schedules and contracts

Dedicated customer service with regular consultations

Compliance with HIPAA, OIG and ICD-10 regulations

By tackling the biggest problems head on, you can proactively engage with the fiscal fitness of your practice in a way that shows real results, all while working to increase your efficiency.

The Quest Diagnostics survey was conducted in July 2019 and had 325 respondents, of whom:

    55% owner/co-owner/partner of private practice
	    21% employed by hospital or institution
	    29% group practice
	    3% accountable care organization
	    8% patient-centered medical home.

Tom Romeo is the general manager of healthcare IT and Quanum solutions at 

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Tackling the biggest problems with your billing

Each new denial is essentially a revenue leak. Even when claims are recovered, the costs associated with that recovery must be subtracted from patient revenue. Recent 

 put that recovery cost at roughly $118 per denial. Factor in the lost revenue from your unrecovered claims and it’s clear why denials are a painful financial drain on practices.  

What makes denials so frustrating is that many are avoidable. The leading causes are well known, and it’s possible to prevent these leaks before they occur. The key is having processes in place to identify and correct errors and omissions before a problematic claim is ever submitted.

Unlike a rejection, which occurs when a submission lacks pertinent data or proper coding, denials are received, reviewed, and found to be inadequate by the payer or health plan. This may be due to insurance plan coverage stipulations, limits, or an untimely filing. Denials cannot be resubmitted, but they can be appealed. It’s the appeal that can prove costly. 

The number one cause for a denial is that a patient isn’t eligible for care under the terms of the insurance plan. In the research cited above, nearly one in five respondents said “registration/eligibility” was the leading reason for denials. The simple step of doing eligibility checks before a patient is seen by medical staff can prevent this. 

 A simple omission, such as date of birth, can lead to a costly denial.

 This happens when a similar or equivalent claim is sent because of a clerical error or overlap in office duties.

. The codes, which determine what is paid, change quarterly, and your practice - or your RCM vendor - is responsible for capturing and operationalizing all updates. 

 You only have so many days to file the claim. 

 A patient’s coverage may have been terminated or their maximum benefit has been met (often in the case of physical therapy).

. Some plans require doctors and practitioners to be “in-network” for coverage.

. Errors can result from submitting invalid modifier combinations. Many invalid modifier combinations can be avoided with better training for coding personnel or by using a qualified medical billing service.

 Some payers want authorization or a referral from another physician before services can be performed.

The complexity of medical billing puts tremendous pressure on practices as many processes are unlikely to catch common errors such as duplicate billing or incorrect CPT codes. This is where technology can be transformative. It can, for example, automate the updating of CPT codes practice-wide to significantly reduce the risk of using an outdated CPT code.

Technology can also assist with prior authorization, guiding staff through the important steps of assessing patient eligibility. While there is no substitute for adequate staff training and education, having a stepwise process to guide staff who process claims ensures the right information is collected and verified before a claim ever leaves the practice. 

A few years ago, a five-person practice in Attleboro, Massachusetts, seeing between six and 15 patients daily, would routinely write off denied claims. It cost them thousands monthly. By adding new technology to predetermine eligibility, the practice addressed its main issue and the number one reason for denied claims: ineligibility.

In the new process guided by technology, front desk staff can verify patient eligibility with the insurance company prior to an appointment. When a patient presents her insurance card during check-in, any issues with eligibility can be addressed in real time. Having this take place beforehand ensures a better experience for the patient and a smoother check-in and billing process for the practice.

Technology and automation don’t replace the human touch patients expect. In fact, revenue cycle management technology, which offers much more than predetermined eligibility review, is enabling practices large and small to focus less on managing loss and more on efficiently and profitably building a vibrant office that provides a better patient experience.

Many practices feel powerless as claim after claim is denied. A closer look, however, reveals that many denials are avoidable. Fix those leaks and you’ll see immediate return to your bottom line. What’s more, you’ll streamline operations and save time that can be put back into delighting patients. Here’s how you can get started:

Audit your practice to see if you’re at risk for any of the most common reasons for denial.

Train and retrain staff to recognize and be vigilant around the key error points that lead to denials.

Consider revenue cycle management technology, which, when properly integrated with your EHR and/or practice management system, can automate critical aspects of the billing process.

Start benchmarking your progress; see how much profit you recoup by stopping leakage that is caused by denials. Focus on “denial rate,” which the American Academy of Family Physicians says should be between 5 to 10 percent on average. Less than 5 percent is more desirable.

Tom Romeo is the general manager of healthcare IT and Quanum solutions at Quest Diagnostics. 

Denials are a painful - but preventable - financial drain on practices. 

Author | Tom Romeo

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