How to plug leaks in your claims revenue

Seven steps to keep reimbursements flowing.

By James Knaub

Revenue leaks are far less obvious than plumbing leaks, but these financial trickles can damage a practice as badly as soggy ceilings or puddles on the floor.

Because leaking revenues don't leave any squishy evidence, we asked practice managers and coding consultants for their thoughts on finding and fixing common revenue leaks in the billing and coding process. Not surprisingly, their advice focuses on the front end in order to submit clean claims that minimize rejections and denials.

According to the Medical Group Management Association, the average cost to rework a single claim is $25 to $30. Improving your practice's claim denial rate not only gets you paid sooner, it also reduces collection costs. Proper training and diligent efforts on the front end of the billing and coding process is the best way to prevent those revenue leaks. These seven steps can help stop revenue claims leaks in your practice.

1. CAPTURE THE CORRECT INFORMATION AT THE FRONT DESK

The first place revenue can leak out of an ophthalmology practice is at the front desk, where staff gathers patients' proper insurance and demographic information and inputs it into the practice management system. A clean claim starts with the correct information typed carefully into the practice management system.

But the front desk at a busy practice is a hectic place. The desire to effectively serve the patients coming into the office can crowd out the crucial task of collecting patient information.

“Getting the front desk to take the time to collect insurance information and get it into the system properly can be a challenge,” says John Bell, practice administrator of North Shore Suburban Eye Associates near Boston. “If they don't get it right, then claims go to the clearinghouse with errors.”

Take a little more time

The claims clearinghouse kicks back most of those problems to the practice, which is better than actually having the flawed claim go to the carrier, but still means someone must track down the missing or incorrect information. Reworking always takes more time than the additional 30 seconds to one minute when the patient is at the front desk, Mr. Bell says.

The job of the front desk is getting more complicated by the number of payers each practice works with and the increasing number of plans those payers offer, as well as the increasing number and amounts of co-pays. Karen Twomey, operations manager at North Shore Suburban, recommends giving the desk staff information sheets that list the insurance plans, including images of the membership cards, that the practice accepts. Such sheets help busy desk staff work efficiently and accurately.

Ms. Twomey adds that just seeing the patient's insurance card isn't necessarily good enough because many patients carry outdated insurance cards. Relying solely on cards can introduce incorrect information into the system. North Shore Suburban is setting up a call center to verify insurance coverage, prompt any needed referrals, and resolve any other patient issue before the patient arrives at the front desk. For established patients, that can be as simple as asking them if their insurance has changed and then verifying information on file. For new patients and those who say their insurance has changed, the desk staff can start eligibility verification. Many billing services offer eligibility verification services and some insurers offer online verification.

2. ACTIVELY PURSUE CO-PAYS AT THE POINT OF SERVICE

It is not unusual for commercial insurance plans to require $40 and $60 co-pays. In the days of $2 and $5 co-pays, the driving force behind collecting small co-pays might have been the fact that insurance plan contracts required physicians make an effort to collect them, but co-pays now represent a sizeable piece of the reimbursement.

Patients tend to know their co-pay amounts and most are prepared to pay them, but don't expect them to offer up. Patients will frequently ignore the discrete “co-pay due at the time of service” sign at the front desk. Train your staff to ask for the co-pay when checking in the patient. Mr. Bell notes that co-pays are frequently printed on insurance cards, so it's not too difficult of a task for your front desk staff.

Some practices handle payments at checkout after the visit. If that's the case in yours, the front desk staff can still inform each patient that the co-pay will be collected at checkout immediately after seeing the doctor.

The I-don't-have-my-wallet excuse

Prepare your staff to respond to the inevitable excuse that the patient does not have his or her wallet or checkbook. How many people go out without a checkbook, credit or debit card? Sue Vicchrilli, COT, OCS, coding executive with the American Academy of Ophthalmology, tells of the alert staffer who responds to the I-don't-have-my-wallet excuse by telling the patient he could reschedule his non-emergency appointment in four weeks. Adopt such an approach — and teach your staff to use it properly — and you might be surprised by how many patients suddenly remember their wallet or checkbook is out in the car.

You can benchmark and track your practice's success in collecting co-pays by adding a point-of-service collection ratio to your regular management reports. Pull one month's total point-of-service collection and divide it by the month's total revenue from all direct patient collections. Like all benchmarking efforts, the most important measure is your practice's improvement from one month to the next.

3. FIND A GOOD CLAIM SCRUBBER

A good claims clearinghouse helps practices get paid promptly and properly, Mr. Bell says. North Shore Suburban uses Navicure. “They do a good job scrubbing our claims,” he says. “We get many claims back before they're submitted.”

While getting claims back from a clearinghouse before they are submitted to the carrier beats having claims denied or rejected, they still need to be reworked. A good clearinghouse can also help your staff improve the quality of the claims they submit. Mr. Bell says the volume of the returned claims when the practice started with its clearinghouse prompted the practice to improve its up-front claims process and decision rules, ultimately resulting in cleaner electronic claims to the clearing house.

4. KEEP CURRENT ON CODING TRAINING

Ms. Vicchrilli agrees that submitting a clean claim the first time is the single biggest factor in timely appropriate reimbursement. A rejected or denied claim typically takes four times longer to research, correct and resubmit than a claim done right the first time. Accomplishing the coding side of a clean claim requires ongoing training in the increasing complicated world of medical coding — and that's without considering the demands ICD-10 will bring when it goes into effect October 1, 2014.

“Coding is not for amateurs anymore,” Ms. Vicchrilli says. She points out that Medicare used to issue coding changes annually and nearly every commercial payer adopted them. “HCFA, now CMS [Centers for Medicare and Medicaid Services], used to create rules and everyone followed,” she says. “Now the way to submit a clean claim varies by payer.”

Medicare carriers use a combination of the CMS coding requirements and the contract carrier's own rules. The variation between Medicare Advantage and other plans adds another factor that complicates the claims submission process, as do the rules commercial insurers impose, which, as Ms. Vicchrilli notes, no longer mimic Medicare.

Global periods are but one example. For minor procedures, Medicare mandates a zero or 10-day global period, Ms. Vicchrilli says. Commercial payers may require zero, 10 or 15 days. For major procedures, Medicare has 90-day global period, while commercial payers may have zero, 45 or 60-day windows. Not knowing your practice's key payers global periods means you could be leaving billable services on the table, Ms. Vicchrilli says.

Besides the rules for different payers, Ms. Vicchrilli notes the frequency of the changes has increased. What used to be annual coding updates have become quarterly updates. One person in the office needs to be clearly responsible for tracking payer changes and communicating them to the billing staff.

Focus on specialty-specific coding training

All this variation requires ongoing coding training for the physicians or staff, or both, who code claims in your practice. It does not make much sense to skimp on training for the people who handle the claims that impact your practice's revenue flow. Ms. Vicchrilli oversees the AAO's considerable coding services and numerous commercial coding resources are available, too. Mr. Bell advises finding specialty-specific training because he has seen too many local general coding refresher courses that spend too much time on topics outside of ophthalmology.

Coding aids help staff efficiently work through plan details. One reference sheet Ms. Vicchrilli recommends contains the fee-schedule allowed amounts for comprehensive eye exam codes — both CPT codes (92004/92014/92002/92012) and E/M codes (99201-99215) — for major payers. Each major payer should have a column on the sheet showing its fee schedule payments for each level of service coded using both sets of codes. Payers' reimbursement can differ between the code sets, Ms. Vicchrilli says, and practice coders should be able to quickly determine the appropriate reimbursement and code accordingly.

If the physicians do their own coding in your practice, they need to participate fully in coding training. If staff codes from patient charts, the physicians need to understand the documentation requirements for all the practice's payers.

5. DO NOT OVERLOOK ADVANCE BENEFICIARY NOTICES

If you plan to provide a service to a Medicare patient whose coverage for the service may be doubtful, the patient must sign an Advance Beneficiary Notice of Liability (ABN) and the claim must include the GA modifier. Ms. Vicchrilli cautions that without the ABN and modifier recorded, the patient is not required to pay for the service if Medicare does not cover it.

While services requiring ABNs might not be a common occurrence in many practices, Ms. Vicchrilli says physicians and technicians also need to know the services for which ABNs are likely to come into play. Such situations include when a diagnosis code might not support a given service, or when Medicare covers a service less frequently than the ophthalmologist might think necessary for a patient. For example, Medicare covers visual field testing for glaucoma patients from one to four times per year, depending on the patient's situation. If you're not confident a visual field test will be covered, an ABN is in order.

Ms. Vicchrilli recommends training staff to appropriately discuss ABN requirements and obtain a patient's signature. “You want qualified staff that can explain to patients why the procedure is important for them,” Vicchrilli said. “You want physicians to be able to say, ‘I practice medicine; my staff deals with insurance and regulations.'”

Mr. Bell adds that Medicare ABNs are not a big issue at North Shore Suburban, but the practice is seeing an increase in ABN situations with commercial payers as they place more restrictions on services. Your practice may need an ABN for commercial plans.

6. WORK YOUR DENIALS RIGHT AWAY

When you receive remittance advice on a claims batch, make sure your staff gets right to work on investigating the reason for denials and rejections. The remittance advice is often ambiguous, requiring staff to track down reasons from the payers, which can be time-consuming, Ms. Vicchrilli points out, at least until staff understands each payer's remittance advice terminology.

The staff's temptation to set aside denied and rejected claims and wait to pursue them in a larger batch is strong, according to Mr. Bell, but that leads to lost revenue. First, he notes the clock is ticking on the appeal and, second, a large stack of denials and rejected claims is a daunting task for staff and easy to put off.

“When you get the electronic remittance advice and EFT [electronic funds transfers], it's time to get to work,” Mr. Bell says.

Besides reworking and resubmitting claims quickly, Atlanta-based health-care consultant Elizabeth Woodcock recommends drafting an appeal letter to accompany each resubmitted claim. The letter should include proof of medical necessity, citing relevant sections of the CPT Manual and specialty society policy statement, she recommends.

One time-honored tip for dealing with claims issues is to have staff obtain direct phone information for a representative in each major payer's claims department. Establishing a cordial first-name relationship with a specific person can go a long way to deciphering denials.

7. PERFORM PERIODIC CODING AUDITS

Mr. Bell and Ms. Twomey periodically perform prospective coding audits on the ophthalmologists and optometrists in the practice; North Shore's physicians do their own coding at the time of service.

This audit involves pulling 10 charts from a physician's case files before sending those claims to the clearinghouse. The auditor compares the charts and the coded claims for appropriate documentation to support the diagnosis, proper codes and level of service provided, modifiers, and any other necessary information.

Producing clean claims is the key to prompt, appropriate reimbursement. If you and your manager provide ongoing training and demand attentive effort from the appointment call to claim submission, the leaks can dry up rather than your practice revenue. OM