The Great Practice Makeover: Undue Burden

March 1, 2009
Laurie Hyland Robertson

A busy internal medical practice learns to push back at payers’ administrative requirements.


At the busy group we’ll call Rural Internal Medicine,* there’s a lot going well. Satisfaction and loyalty run high among patients, staff, and physicians alike. Revenues and cash flow are steady. Their EMR is up and running, with nary a stray scrap of paper in sight at this three-physician Maryland-based practice. Really, everything’s hunky-dory, with just one exception: Payers who continually change their already-inscrutable rules.

“The administrative part is just unbelievable,” says practice administrator Jean Ellis.* “I’m not nasty by nature [but] you really feel as if nothing will get done if you don’t adopt a split personality.” The practice gets it done, but Ellis increasingly wonders whether the time devoted to certain relationships is worthwhile, and she and her billers bemoan the fact that they’re often forced to play hardball - not to mention a constant game of “Mother May I” - with payers.

Although Ellis’ staff seems to be doing just about everything that can be done to make payer interactions as painless as possible, a check-up is sure to uncover additional opportunities to improve. To effectively address these issues, Rural Internal Medicine - and other practices that may not be so adept at playing the payer game - will ultimately need to break them into specific problem areas, looking perhaps at slow payers, eligibility and authorization questions, poor reimbursement, and simply pinning down shape-shifting policies. Here is an overview to get things rolling.

Review of systems

Ellis’ billers track insurer hassle factors by running regular queries from the practice management system, graphically analyzing, for example, response to level 4 and 5 submissions by payer group to detect denial patterns. As a result, the practice now strictly requires that patients sign advanced beneficiary notices, and they’ve made a decision to always “bill what they’re doing,” regardless of the expected payer response. A small sign on the front desk alerts patients that a number of payers are on the practice’s watch list; patients with these plans are advised to seek guidance from their HR departments or insurance brokers to determine whether they might be able to switch to an alternative company.

As insurance company “customer service” becomes an ever more egregious misnomer, patients increasingly look to the practice for information about their coverage. This forces the staff into developing considerable expertise on a myriad of payers’ plans and policies. There’s a tipping point to all this learning, where holding onto certain payers may no longer make sense. Payers that represent a relatively small proportion of patients or those that set up roadblocks to providing good care should go on the watch list, or even be cut. Limit participation only to those plans offering the most juice for the squeeze, so to speak.

For denied claims, focus efforts on the most damaging types. According to revenue cycle management firm athenahealth, coverage-related problems result in particularly long cycle times. Expect to wait up to 40 percent longer to get paid for those claims than for claims denied for other reasons. Clearly, the before-visit, new-patient process merits extra attention. Perform whatever verification activities you can in advance. This is your chance to find out what copay or deductible the patient might be required to pay - and to communicate that information, as well as reiterate your billing policies in no uncertain terms before she arrives at your reception desk, grinning sheepishly and saying, “I’m so sorry - I must’ve left my checkbook at home today!”

Information on patient copays, deductibles, and coinsurance amounts is increasingly available from payers, so make use of it. Many consultants say that online is the most reliable way to obtain eligibility data, and Rural Internal Medicine’s experiences bear this out. Particularly problematic payers, however, may necessitate a multimedia approach - for some, the automated phone system is the most up to date, whereas others’ reps are the prime source for reliable information. Add this to the list of payer quirks to know and track. Unless a payer has full-on real-time adjudication - which precious few currently do - online systems may prove best for general checks of eligibility rather than determining coverage for specific tests or procedures.

Athena and others, such as the consulting firm The Verden Group (through which you can sign up for payer policy change alerts), also maintain databases of evolving payer rules, informed by the claims they process for their clients, so that practices using their services don’t have to expend the energy to keep up. Even the smallest practices are starting to outsource billing and collections in response to the type of difficulties Rural Internal Medicine is facing. As payer rules become more complex, automating billing functions through a revenue cycle management company is becoming more attractive to avoid the tedium - and, let’s face it, the increasing impossibility - of keeping track manually.

Another tactic to make things easier in the long term is maintaining a master file of verification forms for each carrier and group. Take time to update the forms annually (or more often, if coverage changes) and cross-reference them with your denial reports, but you’ll have a single go-to spot for basics, such as copay amounts, along with the payer’s contact information. Organizing the billing and collections teams by payer also makes administration a little easier, as each biller only has to remember the rules of a handful of payers rather than all of them.

Ellis should also selectively approach payers about their rules. For example, if a payer requires preauthorizations but then approves them 95 percent of the time, present that data. Perhaps preauths aren’t really necessary for “routine” care?

More burden-reduction strategies that lie outside the practice itself include a scanning lockbox, which would have the bank receiving and processing EOBs, and remote capture for checks - both simple means of increasing efficiency in the face of rising payer demands on Rural Internal Medicine’s time.

In addition to carefully prioritizing which payer quirks most urgently require staff attention, Rural Internal Medicine should also give top billing to the larger issue of streamlining its approach to payers’ administrative requirements. Perhaps while payer concerns remain initiative Number One, the practice would continue to verify every patient’s eligibility, even though that may not be the best ongoing use of staff effort.

It’s OK to shift your primary management focus, and to create task forces to address particular problem areas. You’ll avoid staff fatigue and the problem of being blinded to an issue, which can happen in the presence of a constant low-level background drone from a host of smaller problems. True, there’s no silver bullet to fix the problem of burdensome payer rules, but resolving the above little things is at least a start toward a larger solution.

* Names have been changed.

Laurie Hyland Robertson is a former senior editor for Physicians Practice. Contact her via physicianspractice@cmpmedica.com.

This article originally appeared in the March 2009 issue of Physicians Practice.