Billing: Finding Lost Revenue

November 1, 2008

We go beyond Billing 101 to show you the advanced techniques and little-known secrets for collecting every nickel, dime, and Spanish doubloon you’re owed.

In the days before managed care, billing was a snap. It seemed you could simply look sidewise at a third-party payer and get paid.

Today, as legalistic coding rules have taken root and payers have gotten stingier, collecting what you’re owed requires fighting a battle on two fronts: the draconian payers on one front - and patients on the other.

You need the latest tools and tactics just to avoid losing ground in this struggle. You can’t afford to keep doing things “the old way.” Accordingly, we’ve asked a coterie of practice-management consultants and administrators for advanced tips on getting what you’ve earned

Notebooks out, pencils sharpened. Class is in session.

Computerize your previsit homework

You’ve heard this advice before:

To ensure a clean claim, collect the patient’s demographic and insurance information before the visit. Practices have traditionally done that over the phone or by mailing patients the usual registration forms for them to complete and return. To take this advice up one notch, post those forms on your practice Web site, assuming you have one (and you should). Patients can print out and complete the forms and then mail or fax them in advance of their visit.

Better yet, enable your Web site to allow patients to complete the forms and transmit them to you electronically (using encryption). Or use waiting-room kiosks to capture the information, rather than handing patients a stack of forms and a pen. Handwritten forms are sometimes illegible, causing staffers to enter inaccurate data that leads to claim denials. At four-physician Northern Virginia Family Practice Associates in Alexandria, almost 100 percent of new patients register online. “Our errors have gone down and our revenue has gone up” since the practice made the switch, says administrator Mary Dooher.

Employees type in the online data just as they would working with a hard copy. What’s more efficient is a Web site that sends registration information straight into your practice management system without rekeying (although you should review it beforehand for accuracy). The major physician connectivity companies - Medfusion, Medem, and RelayHealth - offer such software integration.

Another advantage of computerized registration - whether it’s done on a practice Web site or a waiting-room kiosk - is that you can structure the form so the patient can’t proceed unless he fills in all the blanks. “Patients will skip half the questions if you let them,” says Beth McGinnis, the billing and IT manager for the 120-doctor Iowa Clinic in Des Moines, which has installed kiosks in half of its waiting rooms.

And make sure you’re capturing all the information you need, including patients’ cell phone numbers, says practice management consultant Deborah Walker Keegan. After all, almost 70 percents of adults polled online recently by Harris Interactive reported that they have both a cell and a land line. (Some have only cell phones.) “If you can’t reach them about a past-due balance on the land line, try the cell,” says Keegan, coauthor of “The Physician Billing Process.” Also, you can contact patients during their 9-to-5 jobs on their cells instead of waiting to call their landlines at night, although Keegan suggests getting their approval beforehand to ring their cell.

Clean up your hospital act

Experts say that many practices that earn an A for capturing all their charges in the office are D students when it comes to inpatient charges. It’s not surprising. On the run in a hectic environment and deprived of their usual coding tools, doctors fall into bad habits. “They’re notorious for writing hospital charges on napkins and turning them in late,” says practice management consultant Greg Mertz. So if you want to raise the level of your billing and collection game, get your hospital act together.

Part of the solution is a rounds list - which your hospital may be able to generate - that shows whom you’ve admitted, says Mertz. This list lets billers know what charges to watch for. They can hound Dr. Jones if a charge ticket on Mrs. Johnson in Room 312 never materializes.

Rounding lists can be downloaded into any number of charge-capture programs - complete with coding tools - that you use on a smart phone or PDA. Some electronic medical record programs have inpatient charge-capture modules as well, giving you mobile access to patient charts. Not ready for the software approach?

An alternative, says Keegan, is pairing a doctor on rounds with a nurse or certified coder - call them “humanware” - who can document services and charges. If you’re losing thousands of billable dollars scrawled on hospital napkins that get thrown away, this extra personnel cost may represent a good investment.

One practice that’s taken charge of inpatient charges is 14-doctor Mid-South Pulmonary Specialists in Memphis, Tenn. It posts a master rounding list for its patients in seven hospitals on a practice intranet. Doctors are responsible for updating the list twice a day, noting all consults, follow-up visits, discharges, transfers, and deaths.

Redundant systems help prevent charges from falling through the proverbial cracks. Billers scour doctors’ progress notes for references to any tests or procedures they’ve ordered. Then they thumb through the charges to make sure those tests or procedures are recorded. If they aren’t, they contact the doctor. “They understand that the billing department has the authority to call them any time of the day about missing charges,” Avery says.

Accountability works in the other direction, too. One doctor, says Avery, will occasionally hold back a charge ticket on a hospitalized patient to see if billers will catch the omission. “She wants to know that you’re watching her money.”

At Mid-South Pulmonary, physicians typically submit inpatient charges on the day of service using a printout of an individual rounding list with fields for diagnostic and CPT codes. Many of them fax or e-mail the form to the office from their home after they’ve hung up their stethoscope. Avery says her doctors started becoming sticklers for promptness 11 years ago after they learned that $400,000 in charges had to be written off due to untimely filing. “They had no idea,” says Avery. “They thought they were doing everything right.”

The moral of the story? Teach physicians that discipline and sloppiness each has its financial consequences. They’ll figure out the right path to take.

Have coder, use wisely

Having expert coders on staff is Billing 101. Using them intelligently is Billing 201, says practice management consultant Judy Bee.

“I see too much data entry by coders,” says Bee. “Just copying information from the charge ticket into the computer is a bloody waste of their time. True, they fix problems like missing modifiers and diagnostic codes in the process, but it interrupts data-entry, and that’s a lower-level job anyway.” Instead, “coders should review and correct all charge tickets and then hand them off to data-entry clerks.”

Bee says that highly trained coders make too much money to be used for tasks that a clerk could complete. They’re better-used for “analyzing denials … writing appeal letters to insurers, reviewing insurance contracts,” and other higher-level functions that, when done well, can generate the practice big revenue boosts. For example, Bee recalls a contract that included an absurd restriction - “a limit of two diagnostic codes per claim, as if patients only had two problems.” Such an arbitrary clause could cost a practice thousands of dollars over the course of a year, yet coders might overlook this problem if their time is swallowed up by endless modifier checks and tedious data-entry.

“Coders also should be reviewing charge tickets each year to make sure that listed codes are up to date and the most frequently billed by the practice,” Bee adds. “I like to put those people to work with their brains, not just with their fingers.”

Fix your edits quickly

Everybody knows insurance claims shouldn’t go out the door unless they’ve been edited for possible errors - either by human eyes, or better yet, by tireless scrubbing software. These programs may come standalone or as part of your practice management system. You naturally want your system to suspend dirty claims instead of submitting them as easy candidates for rejection or denial. It’s often a matter of missing information - a modifier, a diagnostic code that would support a CPT code, or the name of a referring physician.

But all too often, practices have no follow-up routine for fixing and submitting suspended claims in a timely manner, so these charges just loll about in the system, says Mertz. The longer they loll, the longer you wait for your money, unless claims stagnate so long that you miss a filing deadline. Avoiding the problem of unresolved edits is another example of advanced billing know-how. “When the machine says, ‘We can’t send this out,’ somebody has to fix this problem,” says Mertz.

With many practice management systems, edits appear in real time as a biller enters charges, allowing her to fix them immediately if the solution is handy. If the edits are unresolved, a good system will let you assign them to the right staffer to remedy. For example, if your edits have caught a missing insurance number, you can put the claim in a work queue for a front-desk staffer. Create a protocol for who fixes what, and by when, says Keegan.

“Edits should be worked as soon as they pop up,” she says. “Unless the problem is out of a practice’s control, they should be wrapped up at least within five days.” To keep everybody on their toes, Keegan advises generating a report tracking the lag time between when a dirty claim is suspended and when it finally goes to the insurer all spiffed up.

Conventionally unwise

There’s plenty of conventional wisdom about following up on unpaid, denied, or underpaid insurance claims. A word to the wise: Conventional wisdom needs some fine-tuning.

Consider this bromide: “Follow up with the insurer if it doesn’t pay a claim within 30 days.” The trouble with that advice, says Keegan, is that each insurer has its own adjudication cycle for clean claims, and it’s often shorter than 30 days, due to electronic claims submission and payment, not to mention state prompt-pay laws. That means you can get off to an earlier start, chasing down accounts receivable.

“Medicare typically pays clean claims within 14 to 17 days,” says Keegan. “Some private insurers pay in 25 days. You need to determine the cycle for each payer.”

Then, set your follow-up threshold by payer accordingly. If Insurer X doesn’t pay up within the customary 25 days, give it a ring on Day 26.

Another piece of conventional wisdom is “Generate an aged A/R report by payer.” No arguing with that axiom. You need this report to spot slow payers. But don’t stop there, says practice management consultant Judy Capko. In a group practice, age your A/R by provider, as well. Capko recalls how such an analysis tipped off a client of hers to a problem with a new doctor: One insurer wasn’t paying the doctor’s claims because his credentialing paperwork had gotten lost. “There were other ways the group could have discovered this, but the aged A/R report was the key,” says Capko.

The same report can yield positive findings. Maybe one doctor collects 75 percent of his money from Insurer X within 30 days, compared to 50 percent for the rest of the group. “Find out what he’s doing right so that everybody else can imitate him,” says Capko.

Practices with a large billing department often assign billers to particular payers so they can master their claims-processing quirks and get on a first-name basis with payer reps. Such specialization has gotten to be standard operating procedure, but be careful how you divvy up payers lest you create uneven workloads, says Bee.

After all, payers aren’t created equal. Some are more prone to slow-pay and denial-itis than others, which increases your work. Some conduct more of their business electronically, which streamlines it. Worker compensation programs are notorious for making you jump through a gazillion hoops. An out-of-state insurer that’s two time zones away also comes with an increased hassle factor. “You don’t want to overburden one biller with all the hard payers and give another biller the easy ones,” says Bee.

So how do you arrive at the right mix? Consultant Elizabeth Woodcock, a coauthor of “The Physician Billing Process,” suggests giving each payer a “relative difficulty” grade, with traditional Medicare being 1, more difficult payers greater than 1, and less difficult payers less than 1. Then calculate what percentage of claims each payer represents, and weight that percentage based on its difficulty grade. In other words, Payer X generates 10 percent of your claims, but because its difficulty grade is an aggravating 1.6, those claims create 16 percent of the practice’s work. If you have six billers, Payer X would be enough work for one of them. (“The Physician Billing Process” includes a detailed description of how to calculate a difficulty grade.)

Collecting from patients

Under the gun to collect more of their revenue from patients, practices need every tool available - basic and advanced - to streamline what is otherwise a very labor-intensive task.

Liberating patient collections from paper is a good start. At the Web site of 80-doctor Physician Associates in Longwood, Fla., patients make credit card payments of roughly $180,000 a year, says Marko Grguric, the practice’s system analyst. While that’s still only 1.6 percent of total patient collections, it’s more than double what Physician Associates took in online in 2006. This up-and-coming technology for collections is available from connectivity firms Medem and Medfusion. Besides being convenient for patients, online payment speeds up cash flow and reduces the number of bills you have to mail out, saving you time and money.

Online payment technology is evolving, as the Iowa Clinic has learned. For years, its Web site could only accept credit cards. Now the group is switching to an online payment service from Galvanon that also accepts debit cards and electronic checks. That’s an important capability since debit cards and checks come with some health savings accounts. “This will expand the folks who pay online,” says the Iowa Clinic’s Beth McGinnis.

These same features come with Galvanon-brand kiosks found in Iowa Clinic offices. McGinnis credits the plastic-swiping machines with garnering more copays and past-due balances. “One obstetrics-gynecology department used to collect about 40 percent of what was out there in co-pays and balances per month,” says McGinnis. “With the kiosk, it’s up to 60 percent.”

Not every patient is comfortable doing business with a robot cashier, so the Iowa Clinic is also willing to take its money at the front desk instead. Tip: Have more than one credit-card reader if you’re processing a lot of patients at the same time. Bonus tip: Invest in a card reader with a built-in check scanner to convert a paper check into an electronic one, debiting the patient’s account that much faster.

Invariably, you’ll encounter patients bereft of greenbacks, plastic, or checkbook at copay time. Establish a consistent policy on whether you’ll reschedule these patients or let them see the doctor and mail in their money later. If you choose the latter route, make it easy for patients to remember their responsibility by handing them a brightly colored, self-addressed envelope marked “copay” on the inside flap, says Judy Bee. “This is low tech, but it really works.”

Customize, automate, innovate

Not every patient will mail in his copay or past-due balance, nor catch up online. You’ve got to chase them down, but go beyond a one-posse-fits-all approach. Keegan recommends tailoring your follow-up based on the credit status of each patient. “There are three basic categories - insured, employed patients with a record of timely payments; insured, employed patients with a spotty history; and uninsured or underinsured patients,” says Keegan.

The collection cycle for the second group might consist of two letters, a single phone call, and a preliminary letter from a collection agency before the agency takes over completely, she says. “The better paying patients could get an extra phone call, because it’s more likely to be successful. You might want to dispense with follow-up calls altogether for the underinsured or uninsured, but as part of your collection policy, you might help them sign up for Medicaid or charity resources from the get-go.”

Technology comes to the rescue for all those phone calls in the form of a “predictive dialer.” This software program, in tandem with your practice-management system, can automatically dial a long list of patients owing past-due balances. When the system detects a live response (as opposed to a recording), it switches the call to a live biller on duty. “Billers spend less time dialing numbers and more time talking to patients,” says Keegan.

The average medical practice uses a collection agency, but for better results, hire two. Divide up past-due accounts between them alphabetically - A through K for one, and L through Z for the other - and watch them compete. “We’ve used two agencies for about a year, and we’re seeing higher collections,” says Beth McGinnis at the Iowa Clinic. “They know we’re comparing their performance.”

Keegan also likes doubling up on collection agencies. “It gives you more leverage in negotiating contracts with them,” she says.

Dual collection agencies is one more trick of the trade for medical practices that dare not take a passive approach toward collections. And new tricks will emerge as the health-care industry continues to evolve, says Keegan.

“You have to stay on top of all the changes - changes with payers, changes with technology, changes with regulations,” she says. “You can’t sit still.”

Robert Lowes is an award-winning journalist based in St. Louis who has covered the healthcare industry for 20 years. He can be reached via

This article originally appeared in the November 2008 issue of Physicians Practice.