Can Independent Physicians Overcome the Medical Billing Hassles?


It has become harder than any time before to a fruitful independent medical practice. As physicians shift towards value-based reimbursement which is gaining traction alongside the fee-for-service model, doctors will be on the hook for demonstrating clinical outcomes and providing seamless care coordination in order to receive payment.

At the same time, independent physicians must also figure out how to meet complex directives such as Meaningful Use, prepare for an influx of newly insured patients, and handle the revenue cycle management in medical billing.

Practices short of a strong medical billing and coding staff might be unable to decide their own course through these changes. They may find themselves financially unstable or having to merge or sell to a hospital.

Amidst altering changes in the healthcare industry, managing medical billing and coding in-house can be time consuming and exhaustive. It requires the staff to spend long hours on administrative tasks associated with income cycle and RCM. On that submitting denied claims can shrink revenue, which directly impacts your practice’s bottom line.

In an attempt to improve practice productivity and regain time spent on tasks associated with billing, is outsourcing medical billing services the answer for your independent practice? To help in your decision, here’s a list pros and cons to ponder upon, when thinking about giving your work to the professionals.

The Pros of offshoring your medical billing:

The Medical billing staffs takes care of all the denied and unpaid claims

 When you let the experts do their job, they are responsible for all claims, having the coding knowledge and training to do so with ease. When doing billing in-house, your practice is responsible for training your in-house biller, which takes both time and money.

Enhanced Revenue cycle is their top agenda

Independent practices small in size may not have an in-house biller who is capable in more than one area of the revenue cycle management. Outsourcing medical billing companies on the other hand will have experts that specialize in the entire income cycle, and are continually up-to-date on industry trends and new revenue cycle practices.

Outsourcing helps you to focus on value-based care

 Having an in-house billing department can be costly, and training staff can be time consuming. Nonetheless, outsourcing can allow you to reposition your in-house biller to focus on value-based related tasks.

Improves the financial health of your practice

A positive revenue cycle is related to practice health, and while some practices are able to stay afloat with industry changes, independent practices may lack the resources needed to do so. By working with professional medical billers, you can greatly reduce the amount of unpaid and denied claims received.

Cons of offshoring your medical billing

The fees associated with offshore billers could be expensive

 Outsourcing medical billing could be costly depending on the size of your independent practice. A great way to evaluate if outsourcing is the right option for you is to do a cost analysis based on annual fees connected with both outsourcing billing in-house to make an informed decision.

Independent Physicians lose control over the billing department

 Lack of control in outsourcing can be worrisome, especially since you no longer have a medical billing department under your control. Although in this case, most of the physicians are relieved by lessening this responsibility.

You think of cutting down your staff

If you have an in-house billing staff and decide to outsource, it’s possible you’ll have to make cuts to staff. But, moving the billing staff to focus on administrative task such as value-based care can be a great way to avoid staff cuts and keep valuable staff members on-board.

You become unaware of the latest Medical Billing Updates

When you have a billing or coding related inquiry, receiving an answer from an outsourced company may take time. Although this can be frustrating at times, it’s your duty to ensure that the contracted medical billing firm has the ability to send you regular updates on your practice’s billing, giving you a weekly or monthly re-cap of where your medical practice stands.

In conclusion we would like to say that the transitioning to an outsourced billing firm solution is the answer for many Independent practices, it may (sometimes) not be the right option for you. Considering the pros and cons of professional medical billing services for your practice specifically is a good way to make a knowledgeable decision, and lead your practice towards a healthy financial status each month.

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Should Doctors Stand Against or with MACRA?


Ever since the election of President Donald Trump the healthcare industry is reeling under pressure of changing regulations and norms. Right from small healthcare units to large medical facilities and from outsourced medical billing and coding companies to insurance providers, all are feeling the heat.

However, the President’s succeeding choice of a former orthopedic physician, Tom Price, MD, did raise hopes among the independent physician community that relief may be coming. But as of now, there is no better embodiment of untenable regulations that have little to do with patient care than the Medicare Access and CHIP Reauthorization Act (MACRA).

For those who are still blissfully unaware (and there are many) MACRA is a program seeking to transition the physician community to payment based on performance and value. This is a well-intentioned goal, and one that many healthcare experts supported at its inception and for many years after. To put it in simple terms, the implementation leaves much to be desired. Also, the persistence to stay the course despite evidence and anecdotes to the contrary, has forever cured the experts of the idea that the future of healthcare could ever safely lie in the hands of well-intentioned bureaucrats.

So, coming to the main question, Should doctors stand against or with MACRA?

As it looks now, there are a number of requirements and suggestions for doctors to be aware of. A reported 84 percent of independent or solo doctors and staff are uncertain of what MACRA demands of them.

Be open to securitize Individual Performance Data and Transparency

The new MIPS system more or less is focused on giving a single score to each individual doctor. All MIPS scores and individual category marks will be posted on the CMS Physician Compare website. The posted scores will give an idea to healthcare providers as to where they fall in the distribution of their peers across the country.

To flourish under the new physician rules they will need to collaborate with their health systems and groups to start thinking of well-organized ways to measure individual performance. Doctors will not just need to get used to getting measured, but they should also know their performance will be available to consumers. This is due to the case of CMS moving towards using transparency to improve performance.

Comprehend the Consequences

 The Fee-for-service reimbursements will be shifted away from and doctors should be aware of how this will affect their facilities bottom line. In a time where medical facilities are encountering a large number of patients every month, the shift from quantity to quality service can be stunting. Under MACRA there is also the potential for penalties to accrue over the years. From the year 2022, the potential financial loss from groups that don’t report data could jump from two to nine percent. This is depending on how well doctor’s score in the four performance categories.

In another scenario, doctors who score extremely high will also be eligible for a 27 percent payment bonus over a three-year period. This is the opportunity for doctors to improve their quality of care and relationships with patients. However, this will require staying informed on the latest measurements and penalties enforced by CMS.

Get plentiful knowledge of the tools that needs to collect data

 Many EHR and analytic platforms currently do not have the capability to track improvement activities and workflows related to the certification of participating in clinical practice improvement activities. Doctors will need robust platforms to track these activities. All this, to show how they have been able to improve their practice and improve their quality of care. You can get help from external sources as well, which is your medical billing department.

In the End…

With the passage of MACRA, the federal government under the Trump administration has made it clear that the move to value-based care is of great importance. One critical element doctors will need to practice is performance improvement through training and measurement. Those facilities that welcome the value-based payment early and develop a culture of transparency, accountability and obedience to evidence-based guidelines with their establishments stand a good chance of thriving through this transition period.

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Physicians achieving Better ROI with Claim Status Checking


A vital undertaking of any medical facility large or small – independent or outpatient is to track or check claim status of a patient’s health cover. With having the knowledge of the claim status many healthcare unit face revenue leakages, which in-turn pushes them towards winding up their businesses (healthcare facility).

How can Physicians achieve better ROI with claim status checking?

You as a physician are busy, the staff is caught up, but staying on top of claims statuses is as important, as checking the patients. Proactively monitoring can keep small issues from turning into claim denials. As a matter of fact, it takes around 5-12 minutes per claim to check status manually and that adds up fast. Most of the time, the healthcare staff spends more energy only to find that the claims in question don’t have a status yet.

A tremendous amount of time is wasted by revenue cycle management experts checking on claims where nothing has happened yet. A technology-driven, automated approach to claim status checking/monitoring ensures resources are being expended where they will do the most good, which is working only those claims that have already been identified as having issues. Medical billing and coding companies are your go-to man in such a scenario, if you feel the in-house department has other issues to take care off.

In this changing climate, revenue must be managed differently to ensure that the value delivered to patients is reimbursed appropriately both in terms of accuracy and timeliness.

Understand claims with context of revenue cycle management

For hospitals and doctor’s office to ensure that their claims are paid, they must first understand how the different components of claims management affect compensation.

Whether you call it revenue cycle or protecting your reimbursement, success will depend on making many improvements simultaneously. It’s not just one small thing that you fix, but making several improvements and making them simultaneously through the process from pre-care to zero balance.

The negative impact improper claims status tracking can have on reimbursement are significantly more pronounced in clinical settings where resources dedicated solely to the revenue cycle are often lacking.

Healthcare experts working over claims management realized it early on that physicians are running the business, but they are not businessmen. They are caregivers, but still they have to manage their practice as a business and claims processing and management was the sand in the gears of practice management.

According to experts, those healthcare organizations and providers succeeding at reimbursement take into account and address how each of the variable components of the patient-provider interaction fit into the revenue cycle and could introduce gaps leading to loss or risk:

Here are some points to ponder upon:

  1. Pre-service (pre-registration, pre-authorization)
  2. Process of care
  3. Process integrity practices (charge master, coding compliance, clinical documentation)
  4. Medical Billing services (customer support, collections, and follow-up)
  5. Administrative services (contract management, fee schedules, debt collections, managed care contracts, denial management)

When you classify your practice or your hospital across these five areas you are then able to address within each of these components – what is working and not working – what are the industry standards –  where are your peers compared to where you are, and lastly what you need to do to get to the next stage and then beyond that.

In simple terms, refining reimbursements begins with assessing the current state of affairs. Experts recommend that physician practices and hospitals pay special attention to three broad functional areas, which are financial, technical, and operational.

Keep an eye open for payer rules and denial rate calculations for a positive ROI

The first step to better the ROI is identifying denials and the reasons behind them. However, saving important claim denial statistics may not be as easy as plugging numbers into a formula.

This is because providers may not have access to claims denial data from payers. Payers many a times are tentative to release the data, especially how often they reject claims, because of competition. They tend to keep the information secluded or restricted to prevent potential customers from passing them up for a payer with a lower denial rate.

As a result, industry averages for claims denial rates generally differ from one report to another. For example, a private sampling agency might report that the denial average overall is between 5 percent and 10 percent, whereas the Government Accountability Office (GAO) found that up to one-quarter of claims are denied.

Do remember that Claims status checking/tracking and medical billing teams not only draw data from across the healthcare organization, but they must also manage different payer rules and medical codes. Using manual processes could slow productivity given the plethora of data needed to successfully manage denials. So go for automated tools.

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What you should watch out as a Beginner in Optometry Billing and Coding?


Running an Optometry business is not that difficult if you have the right kind of resources with you to complete all the tasks. Right from patient encounter to admissions and from checking their eye problems to getting reimbursed via perfect medical billing and coding is a work cycle.

If you are new to the world of Optometry billing and coding, we are sure that you may be wondering where to begin. Unfortunately not much is covered during your studying years, learning about optometry. It has been observed that even after you graduate, you have to begin catching up to your more experienced colleagues in the field.

Learning billing and coding for optometry for eye disease is best done by learning from experienced optometrists. There are a number of coding experts to choose from; however we believe that many of the courses offered are prepared for the broad field of medicine and a 6-hour course that covers multiple disciplines of medicine. They only spend as little 30 minutes on optical disease while covering cardiology, oncology, and primary care medicine.

What are the special needs of optometry coding and billing? Let’s take a look.

Just as in other fields of medical specialty, optometry also has very specific guidelines, rules, and regulations that one needs to adhere too. You have to follow them all precisely for claim submission and reimbursement to the service provided.

Optometry or Ophthalmology services are all medical treatments done to the eye, including vision care and medical procedures done to the eye and ocular area. In such a scenario, for these services to be covered, they have to be performed by the right type of doctor.

Keep in mind that Medicare will only consider reimbursement of ophthalmology or optometry services if they’re done by a provider, whose scope of expertise is within these areas. These experts, more often than not are with specialty optometry medical billers and coders.

In simple terms: eye care services must be performed by eye doctors! If they aren’t, they must be performed only with a medical diagnosis, and only when medically necessary.

Which services are covered for reimbursement in Optometry setting?

The number one thing that beginners of the medical billing and coding of eye care should keep in mind is that Optometry billing services are all very specific. This is due their coverage guidelines are also very specific.

These rules define the types of services that can be performed and reimbursed by Medicare.

That being said, all insurance companies have a different set of rules for claims reimbursement and coverage determinations. So for this you need to refer to Medicare guidelines.

The Medicare guidelines also define other insurance company rules in a very significant way. They are basically the federal government’s determination of reasonable and customary services, which should be paid for.

Furthermore, numerous optometry services will be covered under vision insurance. For beginners it is very vital to know that it is not your typical medical insurance. People have to buy vision insurance separately from their medical insurance plans (same like dental insurance). Some employers don’t even give the option of vision insurance.

Due to this situation, vision insurance plans will vary widely. They range from complete coverage of all eye related services, to one vision screening exam per year, to coverage of only medically necessary eye services performed by a physician and not an eye doctor.

Listen Beginners – Optometry billing for starters is a completely different world

Due to the separation in coverage (which is vision insurance and medical insurance), you can see how the Optometry specialty billing is different to other medical specialties. A vital point to ponder upon is that – in eye services you’re not billing for medical services, but you’re billing only for those particular eye services. They need to be specifically covered under eye insurance and performed by an eye specialist.

Furthermore, ophthalmology and optometry procedures are particularly restricted to diagnosis, frequency, and by provider. It’s very critical to understand all of the guidelines, rules, and regulations when it comes to optometry medical billing and coding for eye claims.

If you have attention to detail, which involves making sure all your check boxes are ticked with regards to coding and billing, be rest assured you have smooth sail in your billing and coding endeavors.

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