Physician practices are very aware of the growing amount of deductible collection that will be necessary with the huge influx of eligible patients under the Affordable Care Act. But while they are very aware, this doesn’t necessarily mean they have measures set up to best prepare for this influx. If they have set preparatory measures, are those measures helping to simplify processes and work flow, or is there now just more work to be done?

All of the physicians I work with go into practice to help and heal people. They didn’t study medicine to then explore the ins and outs of all things payer, billing, and appointment reminders. For those with smaller practices, they and maybe one other clinical staff member are multitasking; handling everything from diagnosis to accounts receivable follow-up, and even eligibility verification. Add back- and front-office operations to that and you’ve got a formula for loss in revenue and harried business operations.
Some of the most prevalent and common issues I see physicians’ practices face include:

• Increased cost in overall operations
• Reimbursements and revenues decreasing
• High deductibles or increased patient deductibles
• Delays in collection of deductibles and other balances due to billing inaccuracies
• Employee compensation increases
• Overall inflation of business operation costs
• Confusion about healthcare reform specifications for small- to mid-sized practices
• Failure or lag in communications through traditional phone calls and mailed letters
But there is a better way: Automating billing and collection systems that will maximize profitability and increase time with patients. While undoubtedly there will be skepticism from some physicians after a decade of the failed promises of enhanced productivity and improved care from many EHRs and other systems, automated billing can be done, and at a cost that won’t elicit sticker shock.
You can:
• Streamline collection methods. This can often be a bane for back-office operations to say the least. Manual collections often result in massive amounts of paper records, hard copy mailings, and staff hours following up with patients on balances owed. Your office staff should be welcoming patients and becoming more involved in their care to help keep them with the practice; not manually dialing phone number after phone number so you can get dollars in the door. Additionally, just because you have the staff to do the office work, doesn’t necessarily mean that work is done cost-effectively and successfully.
• Increase/better target use of communication such as secure text, e-mail, and phone calls. Similar to my above point, free up your back-office operations to do the most important things for your practice. By targeting communication channels specific to your patients’ likes and needs, you streamline your practice operations. You aren’t hard-copy mailing a young patient who only responds to text messages. You aren’t e-mailing a patient who checks e-mail once every month.
• Report non-responsive debtors to credit bureaus and/or legal departments to take the workload off of the practice staff. By automating processes, your staff isn’t bogged down by work when people don’t pay. There are solutions to freeing up their time and making sure your practice profits.
Here’s an example that might apply to your practice: Take a look at your eligibility verification. If each claim denial costs your practice $25 to $30, and you know your denial rate is above the industry average of 3 percent, the monthly cost for eligibility verification in advance of patient visits shows an outsourcing company with this specialty effectively pays for itself.

As a patient, and with friends and family who are patients, I want to know that when I see the doctor that he is able to be clear minded and exclusively focused on my care or the care of my family member.
With automated billing solutions in place, physicians can focus on the practice of medicine, freeing their time to focus on patient care, and work with their office staff to maximize profitability.

By: Vishal Gandhi

– Source: http://www.physicianspractice.com/medical-billing-collections/automated-billing-increase-time-patients-practice-profitability#sthash.5Iobz1gx.dpuf

Most practices are struggling financially due to declining reimbursement and increasing overhead, and many have made changes to increase practice revenue. But according to Rosemarie Nelson, principal with the Medical Group Management Association Health Care Consulting Group, there’s still more that many practices can do to boost revenue.
To help identify some of the best tactics, Physicians Practice asked Nelson to share some of her tips. Here’s what she told us.

Physicians Practice: Based on your work with practices, what are some common areas that you think practices overlook when it comes to boosting revenue?

Rosemarie Nelson: Underutilizing their existing technology (practice management system, EHR, clearinghouse, patient portal, and so on), and their staff. I always find some feature/function in the practice management system or EHR that could eliminate or reduce a manual effort.
For example, in one practice, nurses kept a paper file on tests that they wanted to be sure to track for incoming results. Instead of printing those test orders and filing them and then fingering through them regularly to look for results, they could have used the EHR to filter on only outstanding tests so that they could follow up as needed. That simple functionality would have saved each nurse an hour a day in that practice.

Physicians Practice: Of the areas you mentioned, what do you think could potentially result in the biggest financial improvement for a practice in the short term? How about the long term?

Rosemarie Nelson: Short-term gains can be earned by optimizing technology. Long-term gains will be earned over time in human resource savings. It is easy to see from this one example on filtering open orders for test result management how the hour saved per day per nurse is a short-term gain.
The practice can more effectively use that hour saved per day per nurse in the short term, but over the long term, the practice can restructure staff with resulting cost savings and therefore an increase in profitability.
Examine everything routinely. When a new upgrade or release of your software is available, learn how to take advantage of the changes. Maintaining the status quo in a dynamic environment is not a recipe for success.
Physicians Practice: If a practice wanted to start on a revenue-boosting project today, what would be the easiest area to start with?
Rosemarie Nelson: Well, nothing comes easily! Optimizing technology takes a very concerted effort because it is hard to get people to change behaviors and adapt to methods to get their work done.
The easiest first step is to reach out to your vendor and ask it to provide you with an evaluation of your own operations — what are you not doing with the technology tool that you could benefit from adopting.
Act as your own consultant. Evaluate your operations by doing a walk-through from the patients’ perspective. Where can you be more patient-friendly? Challenge your staff to identify time-wasting activities. Look at redundant steps in each process from check-in, to rooming patients, to discharge and check-out. Do not accept “because we’ve always done it this way” as an acceptable reason to continue.
Think as if you could create it all from scratch and design the process for patient service and efficiency. Maybe you’ll need to invest in more equipment, but do the analysis to determine how a one-time investment can offset the cost of a daily process that is performed 35 times per day.
To learn more from Nelson, sign up for Practice Rx, Physicians Practice’s new conference for physicians and administrators. At the conference, Nelson will share more of her revenue-boosting tips.

By: Aubrey Westgate

– Source: http://www.physicianspractice.com/blog/revenue-boosting-ideas-every-medical-practice?cid=related_teaser#sthash.b0tSHGtm.dpuf

Primary care’s goal, regardless of how insurers pay for it, is not just to improve, but to reliably and consistently deliver the best possible patient-relevant outcomes at optimal cost and to continually improve by cutting waste and investing resources to improve health status.

If, as a primary-care provider, your plan is to continue to rely on fees for service, you are not just short-changing yourself; you will continue to be grossly undercompensated compared to your relative value, and impact, on the overall healthcare delivery system.

No matter what it is called — pay-for-performance, value-based reimbursement, or revenue for results — the only reason not to embrace these new programs is, to put it bluntly, that you are incompetent.

New physician organizations, armed with enabling technologies, put primary-care physicians in charge of the whole dollar of care instead of their respective small fraction, which is about 4.4 percent of the average commercial healthcare spending, or, about $15 per member per month (PMPM) on average. That is out of the average $346 PMPM total Medical Loss Ratio, (MLR) or, the total spending per patient per month in a non-Medicare/Medicaid environment. Adding typical in-office basic laboratory testing and related diagnostics such as EKG among other services, the total average increases to about $18 PMPM.

This means that the typical primary-care physician directly controls (and receives) just 5.2 percent of total healthcare spending. A 20 percent decrease in controllable spending only results in a 1 percent impact to the total spend while rendering primary-care physicians financially unstable, if not financially untenable.

Fee-for-service reductions have exactly the same impact and have been proven to actually increase the overall cost of care.

This is because primary-care physicians affect much more. Improving health status of their patient panel, better managing third-party diagnostics, closing gaps in care and other clinical and quality measures contributes a much higher value relative to total spending, particularly by reducing utilization in the highest cost drivers: imaging, procedures, and hospitalization. Just a 10 percent impact on spending for a panel of 1,500 patients at $34.60 PMPM reduces spending by $51,900 per month, or, $622,800 per year.

Value-based reimbursement in a shared savings environment gives primary-care physicians a share of these savings.

It can’t be done alone except in a fairly constructed Patient-Centered Medical Home (PCMH) program, and then, only rarely. The problem is, without the tools, technology, and techniques in an integrated care environment, most PCMH practices don’t see much gain.

Properly equipped practices (in real terms, not just some care coordination) can generate real results: from 10 percent to 30 percent savings. Dozens of new independent practice associations that provide these capabilities are popping up with many more in the planning stages.

Enabling capabilities include population health platforms, risk, cost, and disease stratification, quality and service metric analytics including the ability to report and close gaps in care, and a clinically integrated network consisting of disease stratified team care organized around primary-care physicians who are ultimately responsible for coordination, documentation, and cost at the minimum.

The most effective are physician owned, controlled, and managed because hospital and hospital system controlled organizations include problematic conflicts of interest.

Choose wisely, and the value in value-based reimbursement is yours. After a 20 percent overall spending reduction in your practice, splitting the difference with the health plan and setting aside, for example, 45 percent of the remainder for technology, expenses, support, training, and overhead and splitting the remainder 80/20 with specialists (otherwise receiving 44 percent of the payer/provider split and 22 percent of the overall savings), the primary-care provider share is about $15.25 per patient per month.

With just 500 attributed patients in the program, that adds up to another $91,500 in reimbursement per year — after fees for service and another $5 or so per patient per month to cover added care coordination costs from the insurer, or, a nearly 85 percent raise.

It takes a lot of work and some uncomfortable cultural and operational changes to achieve these results. But, times are changing and the payoff can be well worth the trouble.

By: James Doulgeris

– Source: http://www.physicianspractice.com/physician-compensation/new-financial-model-primary-care-providers#sthash.4wu9o3ro.dpuf

Previously, each Part B office had their own requirements regarding charging Medicare patients for missed appointments. TRICARE (TriWest Healthcare Alliance) regulations required providers to establish office practice policies regarding “no show” fees and required beneficiaries to sign an agreement taking financial responsibility for missed appointments. Other offices like WPS Medicare only required that provider also charge non-Medicare patients for no shows, too.

Fortunately, CMS now has an official written policy that applies to all carriers in all states, effective October 1, 2007. Under the MLN Matters Article MM5613, providers may bill patients for missed appointments; however, Medicare itself does not pay for missed appointments, so such charges should not be billed to Medicare.

Additionally, providers must not charge only Medicare beneficiaries for missed appointments; you must charge all of your patients, including non-Medicare patients. The amount must be the same for all patients.

You should make sure that your patients and staff is aware that they can be billed for a missed appointment and that Medicare should not be billed. Although it’s no longer going to be required, you may still want to have your patients sign a form stating they are aware of the new office policy.

Author: Cyndee Weston

– Source: http://codapedia.com/article_257_Charging-Medicare-Patients-for-Missed-Appointments.cfm#sthash.LvGOGvAR.dpuf

One of the issues surrounding implementation of the Affordable Care Act (ACA) that impacts physician billing and payment and hasn’t gotten a lot of attention is what happens when a patient buys an insurance plan under the exchange, but then stops paying the premium.

The answer may end up leaving more than a few physician practices fuming over providing free care with little or no recourse.

First, patients have a 90-day grace period to get caught up on their premiums when they are receiving advance tax credits to help pay the premiums. A large number of exchange enrollees will be getting at least some premium assistance.

As a result, patients in this grace period will appear to still have coverage, because they will still have coverage. The final rule published in the Federal Register by CMS on March 27, 2012, establishing the rules and regulations governing the exchanges interprets the ACA to provide the grace period.

During the first 30 days of the grace period, the patient’s chosen insurance company is on the hook for paying any claims incurred by the patient. For the next 60 days, it is the service provider who will either have those payments suspended until the patient gets caught up, or have those payments recouped once the patient’s policy is canceled for the 90-day delinquency.

The objection from health providers is the same one you’re probably having – the lack of information about the patient’s insurance status could result in your practice providing costly services during the 60-day grace period and ultimately not being paid for the work.

The best way for you to figure out if a patient is in the grace period and at risk of having his or her policy canceled is to pay close attention to the claims remittance advice you get for unpaid claims during 2014, though in doing so at least one service will be potentially unpaid.

Insurers are allowed – but not required – to pend payments during the second and third months of the grace period to avoid the liability for patients whose policies are ultimately canceled.

Look for Claim Adjustment Reason Code 257, created on Nov. 1, 2013. The code descriptor is “The disposition of the claim/service is pending during the premium payment grace period, per Health Insurance Exchange requirements.”

Seeing that code is a sure sign that you’re at risk of losing money for that patient, and should consider seeing that patient only on an emergency basis until the premium is caught up or the policy is canceled.

It wouldn’t be advisable to tell the patient you know that he or she is delinquent on premium payments, but you can ask the patient to check with the insurance company to verify the status of his or her coverage prior to being seen.

It’s a small measure, but it’s the best one you may have to guard against providing a large volume of care and getting stuck with the bill. You are allowed to back bill the patients directly when policies are canceled for non-payment, though your chances of getting paid are probably remote.

Author: Scott Kraft

– Source: http://codapedia.com/article_675_When-patient-doesn%E2%80%99t-pay-health-exchange-premium-you-may-be-left-holding-the-bag.cfm#sthash.b15tRwjH.dpuf

Call me crazy, but it is always exciting to me when I assist a practice in getting reimbursed on unpaid or delinquent claims.  Claims that were denied, viewed as uncollectable, past filing deadline, or a multitude of other reasons.  I even have a little dance that I do!  Why not?  We need to get excited about our jobs, and in these times of decreasing health care reimbursement, it is crucial that we push forward and adopt a motto of “NO CLAIM LEFT BEHIND”!  Here are a few tips to help you become persistent in your reimbursement efforts for your practice.

First and foremost, don’t get behind.  I know it seems elementary, but it is very important to have solid Billing Processes.  Set goals and tasks that need to be met daily, weekly, and monthly, and mark them on your calendar to ensure you comply.

Resolve payment denials and other claim related requests as they come in.   Don’t let them stack up.

Communicate denial trends with your provider or other appropriate staff.  There may be coding, office policy, or even staff issues that need to be addressed.  Resolving the issue quickly can help avoid future denials and possible compliance risks.

Identify your delinquent claims on your Aging Report monthly.  Most Practice Management Systems can easily compile this report.  Go through each claim to follow up to see why the claims has not been paid.

Record detailed account notes on what you have done on each claim.  Include dates, contact names, and other pertinent details.  This proves vital when you need to access the account again and take further action on a claim.

Know and understand all of your top Payer guidelines for appeals, reconsiderations, and resubmission of corrected claims.

Develop a QRG (quick reference guide) for all of your payers that includes required information when working your claims.

Finally, take action on every one your delinquent claims and follow through to resolution.  In most cases, persistence will lead to positive results.

The net collection ratio is calculated this way: Cash collections divided by net charges. Net charges are the difference between gross charges and required government and third party adjustments. Use gross charges, insurance adjustments and cash collections for the same time period.

Example: Gross charges = $3,740,318; Cash collections = $2,070,275; Insurance Adjustments = 1,588,554

Net Collections = Gross charges-Adjustments 3,740,318-1,588,544=2,151,764.

Net Collections is what you could have collected after insurance adjustments.

Adjusted Collection Ratio: 2,070,275/2,151,764=.96

This practice collected 96 cents of every dollar that they could have collected after insurance write offs.

From gross charges, subtract only your mandated third party adjustments. Include in these adjustments only those write-offs that you had to take because of your contracts with either the government or other third parties. This would include Medicare and Medicaid write-offs and commercial write-offs, which you were required to take because you accepted the plans’ fee schedule or rules. It would not include write-offs for bad debt, charity care, eligibility or registration errors, coding errors, or late filing. It is important that only these mandated adjustments are included in the calculation.

Subtract the mandated adjustments from gross charges and that equals net collections. The net collection ratio equals cash divided by net collection. A high percentage such as 95% or 98% means that the practices is collecting 95% of all the charges which were allowable to them to collect after the adjustments that they were mandated to take by their third party contract.

The net collection ratio varies by specialty. Practices that have a high net collections tend to be stable practices with a low percentage of new patients and tend to be the medical specialties where patients assume they will come back to see the physician year after year. Practices with a lower net collections ratio might include practices with a high transient population, some surgical specialties where the patient feels they will never have to see that surgeon again, and practices with a high percentage of new patient visits. It is critical for the practice to monitor this ratio monthly and track it over time. Both the Medical Group Management Association (MGMA) and Practice Support Resources have normative data by specialty.