(414) 423-4100 understanding best practices in revenue cycle management speaker: deena wojtkowski,...

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Understanding Best Practices in Revenue Cycle Management

Speaker: Deena Wojtkowski, CPC, CEMC, CCP-P

April 18, 2013


One of the best ways to increase revenue is to ensure that you don’t ignore income sources already in

place. “The lifeblood of a practice is how it captures, obtains and submits billing information” We see a lot

of practices leave money on the table because of incomplete billing practices”

Where do you start?


Pre-Planning the Office Visit

•Determine prior account balance•Verify insurance•Determine co-payment •Determine co-insurance and deductible•Learn pre-authorization requirements•Make demographic/insurance updates•Learn patient’s no-show history


Pre-planning the Office Visit

What about patient’s financial responsibility with insurance coverage?

Areas to consider:•Co-payment: pay before or after service

•Co-insurance: pre-pay or payment plans

•Deductibles: pre-pay or payment plans

•Supplemental Insurance


Pre-planning the Office Visit

What if patient doesn’t have insurance coverage?Areas to consider:

•Pre-service financial counseling/arrangements•Payment plan •Charity care•Sliding scale based on ability to pay•Interest on past-due balances•Pass-through on the collection agency fee


Patient Check-in

•Collect co-pays/co-insurance/deductibles/outstanding balance

- Merchant services- Electronic fund transfer scanner

•Collect past-due balances/no show penalties/etc.•Obtain copy of insurance card – front and back

•Obtain/verify demographics

•Obtain HIPAA signature, waiver forms


Charge Capture and Charge Entry

Surgical / Office Procedures• Fee Schedule•Practice Management System

- Claim scrubber- Claim edit

• Encounter Form

- Update procedure and diagnostic codes annually - Track when provider turns in - Track when submitted to payer (lag time)



• Inpatient Procedures• Fee Schedule• Encounter Form

- Verify charge capture against documentation, such as operative reports, discharge summaries, etc. - Timely dictation and reports - May realize as much as 20% charge increase with

reconciliation process



• Conduct Quality Control Processes

• Coding Audit

•Charge Entry Audit

• Lag Time Analysis


Claims Submission

Clearinghouse

•Conduct a Quality Review of Claims

•Hold Claims Until Documentation is Completed

•Submit Claims on a Daily Basis

• Submit E-Claims


Claims Submission

• E-Claims Checklist• Keep Updated on Claim Formats

•Review and Work Your Claim Edits

• Work Error Reports Daily

• Monitor Claim Filing Deadlines

•Know Your States Regulations about a Clean Claim

• Use Scrubbing Software


Claims Submission

•Clean Claims Checklist

•Institute an Edit Function for Paper Claims

•Review Your Clearinghouse Costs

•Work Suspended Claims

•Be Efficient in Processing Claims


Payment Posting

•Payment Variance

•Determine if you are being paid what you are due

•Payment Posting Performance Checklist

- Cash Batching employee

- Cash Posting employee

- Multiple layers for auditing efforts


Payment Posting

•Payment Posting Audit Tool•Institute Electronic Payment Posting•Establish Appropriate and Effective Internal Controls•Safeguard Checks and Credit/Debit Card Receipts•Make Sure Payers Have Updated Information about Your Practice

•Actively Manage Unidentified Payments•Implement Non-Contractual Adjustment Codes


Payment Posting

•Verifying Reimbursement Level by Payer

•Resolve Credit Balances Within 60 Days

•Develop a Streamlined Refund Process

•Develop a Streamlined Process for Billing Secondary Claims and EOB’s That Need Follow-Up


Payment Posting

•Contractual Adjustments- “Allowable”

• Non-Contractual Adjustments

- Reduction of payment, or non-payment, for a particular reason

•Lockbox Services


Account Follow-up

•Prioritize Account Follow-Up

•Ensure Timely Account Follow-up•Follow up on All Open Claims•Do NOT Automatically Re-bill Accounts•Clean Up Your Accounts Receivables•Identify a Small Balance Adjustment

- 30% of claims submitted for the first time get denied -50% of those claims are not followed up on- Denials Management


Account Follow-up

•Ways to Prioritize Your A/R Efforts- Educate Staff to Follow a Systematic Process- Develop a Systematic Follow-up Process with a Payer

•Payer Collection Checklist

- Use the Internet to Check for Payer Updates- Transfer the Account to Patient Responsibility- Resolve “Information Requested from Patient”


Denials Management •Measure Denial Data and Take Action• Insurance Rejection Log• Graph of Denial Trends•Understand the Payer’s Reimbursement Policies•Decide if a Denial is Inevitable•Rework Appealable Claims•Organize Denial Follow-up Activity•Use denial Data to Redesign Billing Processes•Calculate the Cost of Rework


Denials Minimization

•Appeal Denials•Escalate Denials or Other Payer Issues if Necessary

•Schedule Routine Meetings with Top Payers

•Maintain Records of Inappropriate Denials

•Use Denial Data to Compare Payers


Patient Collection •Establish a Collections Cycle That Works for your Practice and its Patients•Set Protocols for Patient Follow-up• Establish Protocols for Payment Plans

•Budget Plan and Payment Plan Agreement

•Collect When the Patient is in the Office•Follow Up on All Patient Correspondence


Patient Collection •Process Returned Mail Within 48 Hours•Get the Patient Involved to Help You•Track the Volume of Statements the Practice is Sending to Patients•Show Patients How to Read the Patient Statement•Maximize the Use of Statement Notes to Communicate with Patients•Offer Online Patient Bill Paying


Patient Collection

•Establish a Billing E-mail for the Practice•Collect Cellular Telephone Numbers from Patients•Research Coverage for Self-Pay Patients•Report Bad Debt to the Credit Bureau(s)• Develop and Use a Charity Care Policy


Patient Collection

•Charge Billing Fees to Patients Who Don’t Pay in a Timely Manner•Make it Easy for Patient to Pay You

• Include Billing Service Questions on Patient Satisfaction Instruments•Maintain a Record of Patient Inquiries and Disposition

- Use a Billing Inquiry Call Log- Have Dedicated Staff for Patient Inquiries


Patient Collection

•Be Aggressive

•Patient balance options

•The Industry in general says to “hit harder and faster on patient balances”

- Statements every 15, 30, 45 days

- Traditional 30, 60, 90 days

- Total of three statements then to collections


Patient Collection

•Use a Collection Agency

•Obtain Physician Approval to Send an Account to Collections (if required) Without Delaying Its Move to the Collection Agency

•Establish Contracts with Two Collection Agencies

•Establish Appropriate Internal Controls for Collection Agency Funds


Rightsizing the Office

•Do we have the right number of staff?

•Are they doing the right things?

•Are they able to devote sufficient time to their major tasks?

•Are staff members completing the full revenue cycle each month?

•Is your current philosophy, “Just add one more person to fix the problem?”


Rightsizing the Office•Allocate appropriate resources to diagnose and treat the disease, not the symptom

•You need the right number of staff who are performing the right tasks and processes to enable a streamlined revenue cycle

•Do you have the right people doing the right things to get the job done?

•Are account resolution staff cross trained?



•Determine how your staff spend their time•Compare overall staffing with available benchmarks

•Determine benchmark measure of choice and identify specific full-time equivalent (FTE) levels required for tasks•Identify performance workload ranges and compare these with suggested ranges to determine if there is opportunity for change/improvement



•If the performance is substandard, rather than have more staff involved in checking and rechecking work, train staff and provide them with additional tools and resources so they can perform at a high quality

•Train or trade mentality


• Collect what is due on behalf of the physicians and other providers who provide medical care. Reduce your errors, increase your automation and increase your productivity – don't leave money that is due your practice uncollected.



QUESTIONS?

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(414) 423-4100 understanding best practices in revenue cycle management speaker: deena wojtkowski,...

Documents

supplemental insurance

charge capture

paper claims

suspended claims

processing claims

quality review of claims

reconciliation process

payer lag time slide