American Academy of Ophthalmology Web Site: www.aao.org
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June 2011

 
Practice Perfect: Business Operations & Finance
Improve Your Billing, Part Two: How to Stay on Track
By Leslie Burling-Phillips, Contributing Writer
Interviewing Traci Fritz, COE, OCS, Ron Rosenberg, PA, MPH, Brittney Wachter, OCS, CPC, and Robert Wheadon
 
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In this issue, EyeNet expands on last month’s theme—organizing and optimizing your billing process—with tips on keeping both claims submissions and collections running effectively.

Keep Your Charges on Track

“The revenue cycle involves so much more than just submitting claims and collecting payments,” said Robert Wheadon, office manager at the 30-physician John A. Moran Eye Center in Salt Lake City. “It also includes entering the charges from all patient encounters and making sure that each element of every encounter is captured correctly. Meticulous data entry is at the crux of submitting a ‘clean’ claim to insurance carriers, collecting the allowable amount for each service performed and resolving denials.”

Ensure your coding supports your charges. Every service provided to a patient must be recorded and identified as a charge, which is represented by a CPT code (e.g., CPT code 66986 for an IOL exchange). And each CPT code must be supported by a diagnosis, represented by a second type of code—an ICD-9-CM code (e.g., ICD code 364.10 for chronic iridocyclitis). If you have problems with a payer over one of your submitted charges, you will need complete and accurate charge entries in order to make your case.

Audit your charts daily. Although many software applications are capable of “scrubbing” claims to identify and segregate erroneous charges prior to their submission to the payer, not all problems can be identified electronically. Someone in your practice must verify that the input and output matches what actually occurred. “We audit the charts every day for accurate coding and compliance,” said Traci Fritz, COE, OCS, a past chairwoman of the AAOE. “This is an opportunity to discover missed charges, which would mean missed revenue.”

Run reports to spot missing charges. Mr. Wheadon creates a report of missing charges, and then investigates the reason for the discrepancy. “After excluding no-shows, we compare scheduled appointments with charges that should have been derived from those appointments. For example, if a patient came in for a visit today but we do not have a charge for her visit, we have to figure out why and make any necessary corrections,” he said.

Over the course of a year, audit each of your physicians. In addition to daily chart reviews, “we perform monthly audits,” said Brittney Wachter, OCS, CPC, business manager at Excel Eye Center, a 12-physician practice in Utah County, Utah. “This is to ensure that our charge entries are being documented correctly. With a practice of our size, we suggest focusing on at least one physician provider per month. Randomly choose 10 to 15 of the doctor’s charts and assess them for accuracy. Doctors are selected on a rotating basis so each of our providers has charts audited once per year.”

Create checks and balances. You can generate reports from diagnostic equipment. An OCT machine, for example, will produce data each time a test is administered. You can review the data periodically and compare it with what was actually billed.

Juggle your resources. “At our practice,” said Ms. Wachter, “I analyze our status using daily electronic reports. Our billing staff operates based on assigned tasks—which means I know what has been completed and what has not, what is behind schedule and where I may need to assign one staff member to help another to make sure everyone meets their goals and deadlines. By using our computer system in this way, I can monitor the process to ensure we stay on schedule.”

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Keep Your Collections on Track

“When I create my monthly management report,” said Ms. Fritz, “I review our accounts receivable (AR) figures and compare them with past percentages. If we have ‘X’ dollars in outstanding AR, I also want to compare that with the national benchmarks to see where a healthy practice should be and work to achieve this figure.”

Monitor the proportion of AR older than 90 days. “Determine the percentage of your total receivables that are more than 90 days old, calculating from the date of service,” said Ron Rosenberg, PA, MPH, president of Practice Management Resource Group, a billing and consulting group based in San Francisco and Chicago that serves practices nationwide. “Less than 15 percent of your AR should be greater than 90 days old, according to current Academy/AAOE benchmarks.”

Monitor how long it takes to collect a bill. “Another key measure is ‘days in accounts receivable.’ Divide the average daily charge (for the past three months) into the total AR. This represents the number of days of charges that are outstanding, and the average length of time it takes to collect a claim. An acceptable benchmark is between 40 and 50 days,” he said.

The later you follow up, the trickier the reconciliation. Each insurance carrier allots a specific period of time for claim submission. And, the longer a claim remains unresolved, the more difficult it becomes to reconcile. “If a claim has not been paid in 45 days, it is important to contact the insurance carrier to identify the problem,” said Ms. Wachter. “Perhaps the claim was not received, for example, and it needs to be resubmitted. Or, there may be an error with the coding. Regardless of the cause, the problem must be pinpointed and resolved so the claim can be processed and paid.”

Understand the contracts with your payers. If you do not understand the terms of your payer contracts, you cannot ensure that you are receiving the correct payments for your submitted claims. Creating prompts in your practice management software to reflect these rules (i.e., how much is allowed for each service performed) is an efficient way to verify that you are paid correctly. “When we receive a payment from Blue Cross Blue Shield, for instance, the allowable amount is cued,” said Ms. Wachter. “If the dollar amount we received is less than our contract states is permitted, we can address the discrepancy immediately. This occasionally occurs when an insurance company issues a contractual update. Suppose, for example, there should have been a 3 percent increase for certain services as of April 1, but on that date the insurance company failed to update their system to allow for the 3 percent increase. In this case, the carrier will backdate claims and pay them once the error is identified.”

Urge patients to pay at the time of service. Payments should be collected from underinsured or uninsured patients at the time of their visit. Ms. Wachter compiles a daily list of patients with scheduled appointments who have an outstanding balance so the front desk can collect a payment from them when they arrive. Her practice also offers patients a same-day cash discount if their account is paid in full at the time of service. This benefits patients and the practice alike, noted Ms. Wachter. “The patient pays a lower rate, and it eliminates the time and resources that we would have to expend collecting any future payments. It is much easier to collect an outstanding balance when you have face-to-face communication with a patient as opposed to following up over the phone or sending letters.”

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Catch Problems Early

First, know what AR patterns to expect. “I have generated management reports, on a monthly basis, for more than 10 years,” said Ms. Fritz. “You can look at the patterns and know what to expect at different times of the year. You also can know, based on the charges from the previous month or two, how to estimate what your collections should be.”

Next, watch for unexpected AR patterns. If you are not seeing the AR patterns that you had expected, then you need to understand the reason for that. There may have been a change at one of your payers—an insurance carrier may have failed to notify you of a change in its policies and procedures, or perhaps it implemented a new software system that is incorrectly denying certain claims—or the problem may lie closer to home. For instance, if your charge entries are being recorded accurately but you are having issues with collecting outstanding claims, there may be a problem with claim follow-up. “When reimbursement declines, I immediately look at the schedule to see if patient visits have declined. If they have not and the amount of AR has increased significantly, someone in the billing department is not taking the time to research and resolve pending errors to get those items settled and paid,” said Mr. Wheadon.

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Get What’s Owed: 7 Tips

  1. Cut out careless mistakes. Common mistakes include a transposed number or forgetting to include a signature, a modifier or a UPIN.
     
  2. Get the coding right. Reviewing your payers’ Explanation of Medical Benefits will help you to spot problem areas.
     
  3. More billing, less haste. In your rush to get to the next patient, you may fail to note everything on the superbill. (This is one reason to perform chart audits.)
     
  4. Send claims out promptly. Review work flow in your office with a view to speeding up billing.
     
  5. Know your payers. Watch for denial patterns, document phone calls, keep copies of correspondence and—for each of your major payers—try to work your way up the pay scale and find a go-to person.
     
  6. Review all denied claims. And don’t accept “No” when you have the documentation to support “Yes.”
     
  7. Offer extra training. Give staff the time to familiarize themselves with office policies and payers’ contracts, and offer billing staff additional training. For a range of educational resources, go to www.aao.org/aaoe and select “Coding & Reimbursement.”

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