Audit Charge-Capture: Implement systems to assure that an appropriate charge is entered for each clinical service. Use your computer system’s appointment scheduling to compare appointments with charge tickets, identifying missing tickets. For services provided outside the hospital, compare your charges with operating room logs, hospital census, and other outside data.
Cash and Financial Controls: Implement systems to compare and control in-office collections and checks received from insurance companies.
Front-Desk Collections: As co-payments are collected, they should be logged into a list, and patients provided a receipt from a numbered receipt book, with a copy kept at the front desk. If front-desk personnel enter the co-payments into the billing system, those payments should be totaled in a “batch” by the system, and that batch total compared with the total of the receipts and the total of the co-payment log. These collections may also be totaled on a bank deposit, an again, that total compared with the batch totals;
Insurance Payment Posting: Each day’s mail receipts should be totaled into a batch that batch compared with the bank deposit total, and those totals compared with the computer system’s batch report after the payments are posted to the appropriate accounts.
The exact process for revenue control may vary with your computer software capabilities, but you should have some batch control system in place.
Manage Patient Demographics: Update and verify each patients insurance coverage. At each visit, copy both sides of the patients insurance card to ensure that you get the correct claim’s filing address as well as other important information. If you have any doubts, call to verify the patients coverage. (Some insurance companies also have Web sites where you can easily check eligibility as well as claims status.) This may take you five minutes, but that’s less than the 90 days that will lapse while you try to collect payment from a patient who has presented you with invalid insurance information. Be aware that even if the patient hasn’t changed employers and the employer hasn’t changed insurers, the contract may have changed. Most employers renew insurance benefits annually, and changes are common. A difference in the alpha prefix or suffix of the patients identification number might signal that the employer's coverage has changed. Be sure to check these numbers carefully.
Editing Software: Use whatever software tools available to you, including: Code-Linking: Which determines whether your CPT codes are justified by the ICD-9 codes you use; Correct Coding Initiative: (CCI) Which tells you whether you have (or could have) unbundled services and inappropriately charge for additional procedures; Carrier Payment Policies: Your Medicare carrier’s web-site may have local payment policies that will tell you how to bill for certain services.
Daily Billing: File claims daily. Its hard enough to get your claims paid when you send them in. They definitely won’t get paid sitting in your office.
Electronic Claims: Use electronic billing whenever possible. Your claims have a better chance of making it to their correct destination if submitted electronically rather than mailed. They’ll be processed faster and you'll have a printout that shows when you sent them and a confirmation report of when the insurance company received them. This information is vital when you have to fight for payment. If you can produce the report that shows you sent that claim within the time limit, they have to pay your claim, even if the filing deadline has passed.
Clearinghouse for All Claims: Use a clearinghouse to distribute all of your claims. A competent clearinghouse will accept 100% of your claims, sending all those that are accepted electronically, and printing and mailing those that must go on paper. The better clearinghouses have editing software to assure that your claims are “clean”, with edits for the right number of characters and the proper alpha-numeric configuration. In addition, some clearinghouses have the editing software described in step 4, above, available and used in their editing process. Increased competition and advances in computers and electronic data interchange have brought the price for clearinghouse services down to the level where it should not be passed up.
Monitor Payment Levels: It is important to have tools available for the staff person who posts payments to assure payment adequacy. Many insurers are “short-paying” claims, and unless you have a system to catch those claims that are inadequately paid, your practice will be “leaving money on the table”. In addition to monitoring each payment as it is posted, it is useful to generate a report of average payments by payor by CPT code at least quarterly (every three months).
Follow-Up Quickly on Slow-Payors: Generate an aged trial balance (AR summary) report by insurance company each month. If the receivables for any company is seen to gradually increase, with large balances over 90 days, aggressive follow-up with that company should be pursued. Many practices were left with several hundreds of thousands of dollars in uncollectable claims [with some notorious bankruptcies of insurers in the 1990s.] If the receivables for a company continue to rise, and there is a pattern of slower and slower payments, you may need to consider notifying patients with that company’s coverage that you will no longer accept that insurance. Be sure to notify the insurance commissioner or other governing body in your state, and review your contract to determine what actions are allowed, and what kind of notice you are required to give.
Aggressively Manage your Relationship with the Payors: Call about claims that have not been paid within 30 to 60 days. One phone call is worth a thousand re-submissions. Always document the name of the customer service representative you are speaking with and the details of your conversation. This information is vital, especially if you end up having to file an appeal to get your claim paid. Go over explanation of benefits with a fine-tooth comb. Don’t just use the explanation of benefits to post payments; use it to make sure you are getting paid what you are due. Look for unnecessary downcoding, bundling and denials, and investigate. If an insurer gives you continuing problems, notify your state insurance commissioner, insurance brokers, as well as the benefits managers of the larger employers in your area.
Systematically Manage your Medicare Supplements: Make sure secondary insurance is billed. Many Medicare patients have secondary insurance to pick up the Medicare deductible and 20% co-payment. Even when the Medicare explanation of benefits states it crossed over the patients claim to the secondary insurance, don’t believe it. If the claim is still in your system after 90 days, it didn't cross over. Submit a hard copy and don’t forget to attach the Medicare explanation of benefits. If your Medicare carrier bills the secondaries, monitoring is still required. Often, for unexplained reasons, the carrier will stop the crossover billing. Practices have lost thousands of dollars by not monitoring the secondary balances, which have remained unbilled for years.
Avoid Billing - Collect All Co-Payments at Time-of-Service: It costs between $6 and $12 to send monthly statements to patients, so if you don’t collect it at the time of service, you may as well write-off the balance. Collect your fixed co-payments before you see patients, and the variable co-payments such as Medicare, after you see patients, before they leave the office. It will take retraining your staff and your patients and reminding them that “your insurance company requires that we collect your co-payment prior to seeing the doctor” (for managed care) and “before you leave the office” for Medicare. You should remind patients about their fixed co-payment amounts when appointments are scheduled, when reminder calls are made, and when they arrive at the office.
Use your Practice Management Computer System to Manage Receivables: Establish a system for checking open claims each month. Whether you keep track of this information manually or with a computer program, routinely check your list at least once each month and either resubmit claims or contact insurance companies to track down your payments. For patient balances (which should be reduced by tip (11), generate an AR report, by patient, all claims over 60 days, in declining order of balance (if capable by your computer system). Work the claims with the highest likelihood of collection. Consider hiring temporary staff to phone patients with balances in the evening.