A healthy revenue stream is the lifeblood of any healthcare practice, but with so many variables in play, maintaining a steady flow of incoming revenue can be a challenge. It's situations like this which call for investigation into the practice's revenue cycle management.
While it's easy to blame low receipts on patients with unpaid balances or on insurance companies simply not paying, often the issue lies somewhere within the practice itself and whether or not it follows best practices in all areas of revenue cycle management.
Here are three common areas of concern to which you should pay special attention when investigating low receipts:
Coding problems plague many practices. The improper use of modifiers, for instance, can make the difference between proper reimbursement and only partial reimbursement - or even a denial altogether.
It's never been more critical for coding to be accurate, especially in light of the impending ICD-10 changes that are to come into effect. When ICD-10 changes are finalized there will be an influx of new codes - nearly 60% of the 69,000 codes in ICD-10-CM are specific to musculoskeletal and therefore will impact orthopedic practices in a major way. A quality control process should already be in the works in order to ensure your practice is coding correctly from day 1 (October 1, 2015) because there is no grace period. On Wednesday, September 30, 2015 you will be coding with the ICD-9 code-set and Thursday October 1, 2015 ICD-10. A middle of the week transition makes it all the more challenging.
Employing a Certified Professional Coder (CPC) may be the answer to not only improving accuracy but also remaining compliant. A CPC with specialized knowledge in your practice's specialty is preferable.
Claims denials are a fact of life in any medical practice and having a process in place to identify, track, trend, manage, and appeal them is critical. Denials can be attributed to two causes: First, there are simply situations in which payers will deny coverage. Coverage denials may call for specific set of actions based on the information provided from the payor along with the denial. Second, there are preventable denials stemming from errors made during the course of the claims process, the result of improper coding, missing information, or any other error either human or systemic.
Keeping an eye on denials and identifying, tracking, and trending the reason(s) for their occurrence(s) is the first step in reducing the frequency with which they come up. Identify trends and create a plan to put a stop to preventable denials. For example, certified coders should handle more complex cases in order to avoid improper coding and complex denials should be escalated to the certified coder, or an error within the practice management system can be corrected once it has been identified.
Underpayments and Contract Compliance
It's crucial that a practice keeps a close eye on insurance company payments to be sure that they are being compensated as per the contracted fee schedule. It can be easy to make such an oversight, and in fact numerous practices do.
Take the time to improve your tracking and managing of payments by being aware of what you should be getting paid in the form of current fee schedules, choosing a practice management system which will cross-check each payment, Explanation of Benefits against the pay schedule. In our experience, however, we have often found that the practice management system alone does not do a sufficient job at tracking underpayments and contract compliance. We often look to employ additional software and manual processes to ensure that our client's are getting paid what they are supposed to.
It's always important for any business to look internally when examining the reasons behind a lagging revenue stream. Yes, there may be external forces at work, but if a practice's staff stays on top of how those variables are managed, there will be much less chance of serious repercussions and negative effect on cash-flow and the practice's revenue cycle. And this can translate into substantial improvements for your practice's bottom line.