by Marge McQuade CMSCS, CHCI, CPOM
December 12th, 2017
You may think your billing processes are working perfectly, but even the best billing process can take more time than it should to collect and some collections are lost altogether. It could be the staff's fault or yours as the office manager, but either way it's a major problem.
It's not enough to have the "right" number of support staff or the "right" billing system. To bill accurately and get paid promptly you need to seek out chronic mistakes and fix them.
Although the billing staff is often blamed for receivables problems, the potential for billing mistakes may originate elsewhere in the practice, like at the front desk. Accuracy of insurance and patient information is the least of the front-office staff members' duties. Not only is it low on the priority list for them, but many front-office employees resent the billing staff.
In the midst of chaos, information is exchanged — information that you need to bill and collect successfully for the services rendered. If this information isn't correct, you won't get paid. Front-end mistakes can cost the billing office a lot of time and cost the practice a lot of money. Why do practices have "follow-up" billing staff anyway? Many of them spend each day cleaning up mistakes made by the other staff members instead of working unpaid billed claims or denials.
The revenue cycle is everyone's responsibility. Without change, you'll continue to spend money correcting in-house mistakes and delaying revenue.
Although the volume of paperwork processed in the billing office can be overwhelming, it can't be tossed aside. Most of this paperwork contains valuable information you need to manage you’re A/R.
In most practices not only don't they know what their payer contracts state, they don't even have copies of them. Although fees or allowances are the most important piece of information contained in a contract, the administrative requirements are also important. Among these are appeals, credentialing, authorizations, non-covered services, and timely filing deadlines. If you don't have a copy of the contract, you certainly can't negotiate it.
Edit reports, are transmitted back to the practice when claims submitted electronically fail to clear the carrier's or clearinghouse's transmission filters. Although edit reports are often easily fixed, they are sometimes put aside or ignored. Yet because these claims have been transmitted, your software system considers them filed. Thus if they aren't edited and resubmitted, they're almost impossible to track. That's why many practices learn, several months later, of a batch of claims that was never edited and resubmitted. Even if you catch them in time to resubmit them, you've delayed cash flow significantly.
Frustrated by the volume, and lack of time, the billing staff often pile patient statements and HCFA’s returned in the mail to the side to work them later. If that stack of returned mail is left to pile up, no one will realize, for example, that the patient's mailing address has changed, and next month's statements will also get returned or there is a wrong insurance address in the system. Without intervention, your stacks of returned mail are being submitted repeatedly to bad addresses. It is costing money, because each statement costs at least 50 cents to send, and it isn't generating revenue.
Insurance companies utilize explanation of benefits (EOB) for payments, as well as to indicate a rejected service. Since no money is involved in rejections, this correspondence is often put aside. But the reason for the rejection can be found on the form, and the explanation is the key to following up on that service — and getting paid. For example, the insurance company may reject the service for "medical necessity," and the practice could resubmit the claim with a copy of the office or operative note to support the service. Instead, many billing offices are so intent on account follow-up that they don't have time to respond to payer rejections.
You might also receive correspondence from patients with insurance information that your registration process missed. Patients often write on the back of their statements or send a letter with corrected information. Again, if this information is simply put in a pile of mail that had no payment attached, your practice is missing a tremendous opportunity to collect.
Don't let the paperwork overwhelm your practice. Know what it is, and know who's responsible to get it done. Work it, document it, and move on to the next task.
In an effort to improve collections, the billing office may send out appeals, tracers, collection letters, payment plans, and so forth, but protocols and follow-up are often forgotten. Before long, it's too late to collect the money. For example, the billing office sends a patient a collections letter that indicates the patient has 15 days to pay the bill "or else." A year later, another staff member runs across the account again — still unpaid, and with no action having been taken. If you were the patient, would you then pay the bill under such circumstances? Probably not, because it's taken a year to follow-up on an account in which you gave the patient a 15-day deadline.
When working correspondence regarding a denial from an insurance company, it's often necessary to resubmit or appeal the claim. If you don't keep an eye on your progress, your efforts may never pay off. Although sophisticated billing systems can track and monitor collections automatically, manual "tickler" systems such as calendars or files by date can work equally well. The key is to define a protocol and follow it.
No matter how small or large your practice, look for trends in billing glitches. Look for repeated insurance rejections for the same services, claims that are denied for registration errors, and co-payments that weren't paid at the time of service. If you work each account without considering the bigger picture, you'll never be able to overcome the problems. If you're in the trenches working each denial individually, you'll never fix the broader problem.
To stay ahead, watch for internal mistakes. Keep a folder for each of your major payers. In it, have your billing staff place examples of problems. Address them during staff meetings, and integrate time of service collections and accurate registration into the performance evaluation of front office staff.
Insurance companies won't pay for your mistakes. Since they make money by holding onto yours, they love for you to make mistakes. Identify the problems that come up chronically, and resolve to fix them.