It’s all too easy for many claims to “fall through the cracks.”

No matter how good we are as physicians and how well we document our work, our practices will be crippled or destroyed if we don’t make sure accounts receivable (AR) is managed aggressively. EMR has certainly helped decrease the number of rejected claims, since it demands specific data be entered in order to bill for a specific level of care, but claims are still denied nonetheless; if this is not addressed promptly, lack of incoming payments will adversely, and significantly, affect the practice’s cash flow. Further, these “kicked back” claims stack up quickly, and soon become overwhelming to the billing staff.

Now that I have emphasized the dangers of a passive AR, read on for some solutions.

DO YOU KNOW HOW MUCH YOU HAVE OUTSTANDING?

Promptness is everything

As you are probably aware, claims must be submitted within a specified time frame relative to the date of service. If the initial statement, or the scrubbed statement after rejection, is not sent to the clearinghouse per guideline, it will be permanently denied due to “failure to timely file.” I have audited several practices that I was considering buying from retiring ophthalmologists and optometrists, and have been amazed at how much income has been left on the table as the result of aged AR — hundreds of thousands of dollars not collected or refiled after denial. Some of it was salvageable, thankfully, but a great deal of it was lost for good.

Aside from the loss of income, this also negatively impacts the valuation of the practice for sale. The same principle applies to practices considering a relationship with private equity.

So much for the “pros”

What’s worse is that many practices outsource billing and collection services, and neither the administrators nor the physicians may know how aggressively these busy organizations are going after your hard-earned dollars, nor when and if they scrub and refile denied claims in a timely manner. And while some services will provide periodic reports on their success rate, others do not.

Another factor to consider: Whether these services are performed in-house or outsourced, with more and more claims coming in every day, sometimes billing staff end up ignoring or — even worse — writing off rejected claims rather than scrubbing and re-filing them.

WHAT SHOULD WE DO?

First, the patients

Let’s divide collections into two categories: Patient responsibility and all other third-party collections. Regarding the patient portion of the bill for goods or services we provide, communication is the key. This begins on your website under the section describing billing practices and the insurance companies with which you contract.

Make it clear that some services are not typically covered by insurance (elective or cosmetic procedures, refractive corneal and lens-based surgeries and products such as Botox, glasses, contact lenses and other peripherals) and that payment is requested at the time these services are rendered or products are dispensed. Methods of payment should be listed, including cash, check, credit and debit cards accepted and payment plan companies with which you work.

Statements should be mailed shortly after the patient encounter and should clearly explain the portion of the bill for which they are responsible. If the patient does not respond, calls should be made and documented in the patient’s file. Communicate with the front desk or scheduling staff about delinquent accounts before the patient’s next appointment (usually done automatically by flagging this issue in the computer); this way, the patient is aware he or she must zero out the account before future services are provided.

If necessary, the practice should have a good relationship with a collections agency. These can be surprisingly successful at collecting monies thought to be lost for good.

As for third parties

To increase your chances of successfully collecting from this group of payers, adhere to the following guidelines:

• Know your payers’ timely filing regulations
• Collect all co-pays at the time of service
• Understand the deadlines for appeal procedures
• Be persistent with payers on appeals
• Know your clearinghouse — follow claim files for successful delivery to payers
• Follow up with the clearing house on rejected claims
• Run reports by oldest date of service — this should be your first priority.

FINALLY …

The Medical Group Management Association summed it up best. I can no longer find the exact citation, but the advice went something like this: “Work aged AR from the bottom up. Take your claims more than 90 days overdue and sort by payer. Run the report at a line-item level. Look for repetitive patterns and what remains unpaid. Many times, you will find the claim partially paid with residual line items outstanding. Was it a non-covered service, or was it linked to the wrong diagnosis, missing a modifier or bundled with another procedure?”

Don’t just resolve a problem — get to the root of the issue and find a way to prevent it from reoccurring. OM

Steven M. Silverstein, MD, FACS, is a cornea-trained comprehensive ophthalmologist in practice at Silverstein Eye Centers in Kansas City, Mo. He invites comments. His e-mail is ssilverstein@silversteineyecenters.com.