STRATEGIES FOR YOUR ROLE IN CONTROLLING THE REVENUE CYCLE

You want to get paid for the work you do. And managing your revenue cycle is the key to achieving this. But there are lots of things that have to go right in order for you to capture the maximum revenue for the services you have provided. And before you start a diatribe about insurance companies, I want you to recognize that all of the items listed here are things that you and your office can control.

• Patient demographic information must be correctly entered
• Insurance information must be correct and up to date
• If the patient wants to use their in-network benefits or does not have out-of-network benefits then you must be in-network
• The proposed procedure either needs to be a covered benefit or patient must agree to cover non-covered services
• Prior authorization must be obtained when necessary
• Documentation in the EHR must clearly show services provided and medical necessity
• CPT and ICD-10 codes must be correctly applied
• Claims must be filed within the specified timelines for each payor
• Denied claims must be reworked and resubmitted (also within specified timeframes)
• Patient balances must be collected

Unfortunately, many physicians that “revenue cycle” refers only to the claims process and that every delayed payment is caused by an insurance company. In reality, revenue cycle management starts from the moment the patient is scheduled and ends when all of the money for that service has been collected. It encompasses every part of the patient care process and involves everyone on your team. Most importantly, you shouldn’t blame denials and payment delays solely on the insurance companies. More often than not, denials and payment delays are preventable. And, while the reasons may vary, inefficient or broken processes and lack of technology in the physician practice impede getting paid faster and with less effort.

COMMON MISTAKES THAT DELAY PAYMENT

Here are some of the most common mistakes that can result in either your money being delayed or not getting paid at all:

• Data entry errors at the time of scheduling
• Errors in manual data entry when information is transferred between systems
• Incomplete documentation
• Inaccurate coding
• Missed deadlines to submit a claim or rework and resubmit a denied claim
• Not informing patients about their payment responsibility upfront
• Not collecting patient co-pay, co-insurance or deductibles upfront
• Not following up on patients’ unpaid balances
• Not collecting any patient balance before the next appointment

Tips for Getting Paid Faster and With Less Effort

Use these tips and you will see an improvement in your revenue cycle management:

Verify patient information on the first phone call

Name, address, birthdate, insurance ID and email

Verify that your provider information is correct on all claims submissions

Address, name, contact information, NPI

Verify insurance eligibility twice

At the time of scheduling

The day before the appointment—especially if there is a significant lag period between scheduling and when you actually see the patient.

Remember that patients switch jobs or have other life circumstances that may result in either an insurance change or a loss of insurance. You can’t expect to get paid if you’re billing the wrong party.

Use software automation features of your practice management software in order to make this easier.

Collect upfront when possible

Provide an estimate of charges to the patient and collect as much as you can either before (at check-in) or immediately after the appointment
(at checkout).

Make sure you have a signed financial policy statement including a credit card on file

Confirm the credit card number, expiration date and security code to make sure that there is no data entry error

Provider documentation

Train providers and staff on proper documentation so coders and billing staff can quickly verify and complete claims

Anticipate any additional documentation that may be requested and submit it proactively

Stay updated on changing codes

Use the most recent CPT and ICD-10 codes to code the highest level of specificity to get maximum reimbursement.

Create workflows for denied claims

Assign staff to immediately investigate and re-work denied claims so you can submit them before the deadlines pass

You may use a billing company to work your denied claims. But frequently, the claim is denied because something is missing (e.g. documentation medical necessity) that only you or your office can provide. Addressing these requests for more information and denials needs to be a priority for you and your staff.

Aggressively work any remaining patient balance

After the insurance company pays you, the patient may still owe you money. Have a process for sending out statements and addressing outstanding patient balances. Any balance should be paid before the patient returns to see you.

Don’t assume that any issues you have getting paid are due to the insurance company.  Your active participation in managing the revenue cycle will enable you to collect all of the money that you are entitled to. No one watches your money like you do.

Be sure to check out The Private Medical Practice Academy podcast and join my Facebook Group, The Private Medical Practice Academy to learn more about business of medicine. Sign up for The Practice Building MD newsletter to get the tools you need to build a successful and lucrative medical practice.