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Once practices have reports on their financial data, they should know what to look for and when to suspect underlying problems.
Measure and monitor: It’s a common refrain of practice management consultants when working with struggling medical offices. To be successful, you have to keep on top of key metrics, such as patient collections and claim denials.
But once you have the reports in hand, what do you look for? What constitutes a "red flag" and how do you identify problems that may be driving worrisome trends?
The first step is making sure someone is actually reading and interpreting the reports and communicating issues with the rest of the staff, said Reed Tinsley, a Houston-based healthcare accountant and business advisor. Regular staff meetings are essential to keeping everyone on the same page about revenue cycle performance.
Once that information has been distributed, everyone should feel empowered to flag potential problems and bring them up at staff meetings, said Cynthia Dunn, a Cocoa Beach, Fla.-based independent consultant for the Medical Group Management Association Health Care Consulting Group. Good communication between coders and clinicians, for example, can help prevent repeated documentation errors that lead to denials.
Experts offered these five tips for catching red flags and following up on financial reports:
Present the big picture. You can run dozens of reports but you won’t see improvement unless someone puts all that information together and highlights potential problems, said Tinsley. "Someone, typically the business or office manager, needs to stay on top of things," he said. "There needs to be a forum, at least monthly, where that person reviews and discusses the revenue cycle performance numbers with all staff."
Be alert to operational issues. Consistently low front-desk collections are often indicative of operational problems, such as inadequate staff training or inefficient workflow, experts said. For example, front-desk staff should be prepared to answer questions from patients about copays and deductibles and have easy access to the business office. “Sometimes the receptionist is told to collect a certain amount, but when the patient asks what it’s for they don’t know," said Dunn. "Then they call the business office and get voice mail - meanwhile the line of patients to check in gets longer."
Be proactive about claims issues. If you’ve addressed a billing or coding issue but continue to get denials, don’t let it slide, said Tinsley. "Meet with the payer’s representative about why you’re getting the denials," he said. "You should always question repeated denials and try to fix the problem."
Adjust for ICD-10. The frequency and type of denials you receive from payers is likely to change under ICD-10, so you need a baseline for comparison when you’re running reports, said Dunn. "Practices need to know their top 10 codes for denials for their top five payers, so they will know if they are increasing or changing under ICD-10," she said.
Look for trends. Underpayment by insurers is a significant problem, but often practices overlook them because they do not compare their reimbursements with the payers’ allowable charges, said Tinsley. He recommended generating a report in your practice management system listing the allowable charges of your top five payers alongside your 25 most frequently used CPT codes. "When someone posts a payment, the system can flag any discrepancies," he said.