From the appointment scheduler and receptionist to the person who posts payments, sound policies and thorough training are essential to ensure efficient billing and collection operations. A good billing department starts with hiring—procedures should be in place to thoroughly check references at the interviewing stage. Practices often hire billers who have little experience or who left another practice because they weren't competent. Make sure the billing department has the right people who have good experience, and make sure it has the resources it needs to file clean claims on time. Examples of such resources are sufficient numbers of staff, support for continuing education to stay abreast of changes, and appropriate computer tools and training.
The biggest problem is that the billing staff do not follow-up properly with denials of claims. When the claim comes back denied, they just resubmit it. Then it is denied a second time because it's a duplicate claim. After three denials, they can't track why it was denied in the first place. Part of every day in the billing department should be dedicated to denials and fixing problems. In resolving a denied claim, as a first step the staff must scrutinize the explanation of benefits to be sure they understand the reason for denial, because different payers use different codes for denial reasons.
An important report for monitoring the soundness of your billing and collections operations is the aging analysis. This report shows monies owed to the practice. It is divided into categories based on how old the bill is from the date of service: 0 to 30 days, 31 to 60 days, 61 to 90 days, 91 to 120 days, and more than 120 days. The amounts within each category may be divided further by payers, so that you can easily see if you are having trouble with claims submitted to a certain payer. If your aging report shows a significant number of claims that are 90 days old or more, that's a sure sign of inefficiency in resolving denials of claims. Experts advise that the percentage of accounts older than 90 days should not exceed 20%; some say 15%.
You may feel overwhelmed and even a little intimidated by billing and collections. However, it's important to start by understanding the process, even if someone else will ultimately be responsible for the day-to-day management of it. By taking ownership of this part of your business, you can ensure timely claims submission and avoid fraudulent activities. The billing process begins with verifying insurance eligibility and collecting the patient portion (co-payments, coinsurance and deductibles) at the time of service.
The practice should have standard procedures to confirm insurance coverage and verify that the patient has obtained any needed referral. Management experts suggest preregistering new patients by phone because of distractions at the reception desk that can lead to errors. Preregistration also allows the staff to verify insurance coverage with the insurance plan in advance of the patient's first visit.
If a preregistration process is in place, ask arriving patients to review the information collected to check its accuracy. At the first visit, copy the insurance card, and make sure the identification number and name exactly match your office record—no nicknames, for example.
The amount of patient co-payments and annual deductibles is rising, adding to the importance of collecting them promptly. Collecting from the patient in person obviates the overhead costs of billing and enhances cash flow. For cancer patients, the services rendered and therefore the co-payment amount may not be known until after the physician sees the patient, so set up the process for collection at the end of the visit.
In addition to starting the payment process more quickly, daily billing reduces the effect of a potential submission problem such as a transmission disruption or a lost packet of mail. If claims are batched by the week or month, such an adverse event could affect a large portion of income.
Once you create a standardized and measurable billing process, you need properly and thoroughly trained staff members to implement it. It's never wise to skimp on this step or assume that only the staffer who submits the claims needs training. A healthy revenue cycle begins with a well-trained front desk staff who have the tools available to check patient eligibility and benefits, and the ability to collect patient balances at the time of service.
A number of software products and online tools are available that will check claims for errors. Some check only for generic errors such as ZIP codes with six digits or a day of the month that is greater than 31, whereas more sophisticated scrubber programs check for required prefixes or suffixes in patients' insurance identification numbers and have edits to check compliance with Medicare's Correct Coding Initiative. Your practice management system may have a built-in scrubber module that incorporates all of these edits. If it does not, discuss options with your software vendor to find the right add-on program or Web-based service for your practice. If you use a service bureau for billing, find out what its claims-editing software includes. Practices that put effort in submitting clean claims, including using a sophisticated claims scrubber, report achieving denial rates of less than 1%.
By maintaining consistent and open channels of communication with patients' insurance carriers, you are laying the groundwork for straightforward resolution of problems when they do arise. Practice's management team regularly review the charges, payments and collections of its top 10 carriers. These are the contracts that generate the most revenue, and any problems have a greater influence on overall revenue. By staying on top of the latest healthcare laws, federal and state regulations, and insurer contracts, you also position yourself to advocate for your practice and your patients when faced with denials.
If you find yourself lagging behind in billing or failing to keep up with current regulations, you may want to consider outsourcing all or part of your billing to third-party specialists like Medical Billers and Coders (MBC). Medical billing companies are up to date on billing regulations and can be an ideal resource for smaller practices to ensure proper claims submission. They also free up your staff to focus on work more central to your core mission. By offloading some of the tedious tasks, like following up with insurance payers on outstanding claims or printing and mailing patient statements, to a company that specializes in medical billing management, practices can save staff time and resources.