A Practice's Responsibility in Managing Medical Expenses
November 25, 2014
Medical expenses are one of the largest expenses in many United States households. Medical bills and insurance remittance are also possibly the most difficult of all bills for patients to interpret and understand.
Of course, this lack of understanding often has a negative impact on many things, such as: provider/patient relationship, provider or practice reputation, patients discontinuing care and possibly even legal ramifications for the practice, if errors or fraud are suspected or discovered. By evaluating some fundamental steps, we can help to minimize the concern and confusion that often occurs with patients regarding their medical expenses in our practices.
There is a great need for the improvement of communication with patients. Additionally, many practices should address the proper management of all billing and collections related efforts. By doing this, you are certain to improve the quality of the patient experience and reduce risk and error on behalf of the provider. Every provider's office, regardless of size must take greater responsibility for their role in providing not just quality patient care in terms of services rendered, but also quality patient care in terms of patient account management and patient communication when relating to finances.
To further discuss these critical elements and the responsibility of the provider, the remainder of this article will detail specific criteria that should be very thoroughly addressed in every practice. Providers that execute these steps are sure to enhance their patient relationships, improve their own and their staff education and efficiency as well as probably even save staff time and valuable practice money in fines and penalties for unnecessary oversights and errors.
Providers should implement and regularly train for proper billing, coding, collections and patient communication. This quality control measure will not only improve and better ensure a quality patient/practice relationship but also serve as protection for every practice and every patient within.
At a minimum of once per year, the following trainings should take place with all applicable staff, doctors included.
Review of all paperwork: Any updates (no matter how slight) to paperwork regarding finances must be provided and updated with each patient to which it applies (financial policies, etc). Paperwork should be carefully reviewed so as to ensure that necessary detail is clearly included. Most medical practices have included onto their financial paperwork that the patient is responsible for understanding his/her own policy benefits and limitations. While this is true, it is a common misunderstanding by patients and is easy for them to overlook as they fill out paperwork. When appropriate, practices may find it beneficial to address these important things directly with the patient. Verbal communication can go a long way and it is often a good idea to encourage patients to become familiar with their own insurances.
Financial consultation: Patients deserve the courtesy of having the financial detail discussed with them and questions answered up front, regardless of the patient case type. Patients must be clearly informed of the financial role they have as well as the financial role their insurance (if applicable) has. It must be made clear that insurance benefits are not guaranteed and that the patient is ultimately responsible (a large number of patients are not clear on this important point which causes confusion and anger when insurance payment is not as expected). A patient's trust and respect for a practice is improved when he/she knows who to go to for questions and concerns and is confident that these things can and will be clearly answered/explained.
Insurance Verification: Practice employees should understand how to clearly and completely collect data when verifying benefits. Verifications should be dated and initialed or signed by the staff member that obtained the information. Complete information on the payer representative that provided the information should be recorded as well. Patients should be offered or automatically given a copy of this verification of benefits. Insurance verifications are not a onetime event. Verifications should be redone anytime a patient changes insurances as well as once per year (usually at the beginning of each year when most new cards are issued) because most policy/benefit changes take place at this time.
Over the Counter Collections (OTC): Doctors and employees should review when and how OTC collections are handled. How does the employee responsible for collecting know the proper amount? How is petty cash recorded and stored? How are credit cards and batch receipts managed? How are all payment types (cash, check, credit card) posted to your accounting system? Are OTC collections balanced at the end of each business day? What verbiage is used to communicate balances and charges with patients? Are charges clearly explained and patient's questions clearly answered?
Insurance Collections: Training to clearly read and interpret insurance remittances should be conducted and discussed in detail so as to ensure proper understanding of how claims are processed. Billing employees must be able to verify that claims were processed correctly. If something is missing, doesn't make sense or needs to be appealed, how does your practice handle this? Review proper posting of payments to gain confidence and certainty that payments are properly posted, required write-offs are properly posted and patient balances are correct. How is the insurance follow-up and resubmissions managed in your practice? Is this system efficient? How is Accounts Receivable managed, particularly relating to insurance claims? Is this regularly reviewed and addressed?
Coding & Billing: Regardless of the patient case type, there are requirements that each practice must adhere to in order to be compliant with local and federal rules. Every practice has the responsibility to evaluate their own compliance and learn of the current guideline that is to be followed. The fee schedule should be reviewed annually. Complete descriptions, thorough supporting documentation and CPT/HCPCS code use should be evaluated to verify that it is all complete & correct. Diagnoses coding should be evaluated as well so as to make sure that the provider has properly supported services rendered. Review all service and diagnoses codes used. Modifiers should be reviewed as well. The most thorough way to review coding and billing is to conduct a GAP Analysis (contact ChiroCode for steps or see Gap Analysis article). If something is missing from a record or more information is needed, what is the procedure for the practice to properly collect this data from the provider? What is the system for data entry and is this correct and efficient? What is the system for billing and is this correct and efficient? Are all claims reviewed before submission?
Patient Billing: Carefully review patient billing procedures. How often are patient invoices sent? Are invoices all sent regularly and in a timely manner? If patient billing is detained for some reason (possibly difficulty with insurance processing) and the patient becomes upset for receiving a bill later than expected, how is this handled? Does your practice have a collection system for unpaid balances (phone calls, letters, etc)? Is this collection system efficient and successful? Do patients call with questions regarding balances and are their questions clearly answered? Are patient balances reviewed to ensure they are correct, particularly those where patient questions have risen?
All practices and providers must evaluate each of these things regularly in effort to improve on and/or maintain quality control. Of course, specific details for these responsibilities should be recorded in practice manuals, updated accordingly and all trainings should be dated and recorded as well. A sound Compliance Plan will address all of these areas and more, as well as allow for optimal record keeping and management of all office policy.