Tag: Reimbursements

16 Apr 2016

10 considerations to avoid billing disruption during a physician group merger


There are several things consider to avoid disrupting billing when two physician groups come together. Here are a few to consider:

1) Identify list of insurances that the combined entity would accept.

2) Determine credentialing timelines for top 5 insurance companies. For example, Medicare takes 90-120 days, BCBS takes 45 days, United Healthcare/ Oxford takes 60-120 days and so on. This sets the timeline for the billing start date through the combined entity.

3) Determine billing data and system setup timelines. Consider the following:

  • practice management system setup
  • receiving a submitter ID from the clearinghouse
  • setting EDI/ ERAs
  • establishing HL7 connection between systems (if needed) and any data migration needs

4) Determine risks during credentialing with commercial carriers. For example, certain carriers tend to automatically delist providers from the previous Tax ID after enrolling with the new one. This may not always be what is wanted (e.g. providers could still serve in the ASC that is associated with the older Tax ID).

5) Consider secondary providers and their credentialing. Would you billing for nurse practitioners? Are there pathologists or anesthesiologists to consider?

6) Would the new entity use a common lockbox? If so which group’s bank to use?

7) Who would be the managing employees and authorized officials of the combined entity?

8) Determine common patient financial policies that would include:

  • common consent forms
  • number reminders to be sent before sending patients to collections
  • default payment plan
  • mode in which payments would be accepted
  • Write-off and billing policy for non-participating insurance plans
  • No-show and cancellation charges

9) Determine a common insurance refund policy. Would it be immediate or as payments occur?

10) Determine access controls for financial and administrative reports of the combined entity.

09 Apr 2016

More patients may not mean more collections


We live in a ‘more world’ where more of everything seems to indicate that we are doing better. The reality that this may not necessarily be true occurs to us in quiet moments. This applies to medical care too. More medicines cause more diseases instead of fixing problems. When doctors see more patients with the objective of increasing collections, it almost comes at a cost. When we examine data, we find that increasing patient volumes (just for the sake of doing so) may not translate to greater collections (or payments) from insurance companies.

Quality of patients and the care they get is more important than the volume in the long run. Let’s conduct a simple experiment. Select all the patients seen by a doctor for one week from two months ago (by this period, majority of the insurances should’ve reimbursed). Conduct a basic payer mix analysis (mix of insurances that patients have) and procedure mix analysis (consults/ procedures that physicians performed – from office visits to colonoscopies. Tracking payments for all these visits/ patients reveals that most of the money (upwards of 90% some times) comes from 5 or so insurance companies. From a business standpoint, could we stop adding patients for the purposes of making more money and focus on the ones we have – so that overall quality of care improves?

Freed up time may then be used to extend care to those who really need it, regardless of what insurance they carry or their ability to pay. It would be far more fulfilling to deliver care without expecting reimbursement than doing so by expecting high reimbursement and be frustrated later with the ‘system’ when insurances delay or deny pay.

09 Apr 2016

Top 10 surgical services at Ambulatory Surgery Centers (ASCs)


According this article, most frequently reimbursed services in an ambulatory surgery center (ASC) setting are below.

All belong to three specialties: ophthalmology, gastroenterology and orthopedics.

  1. Cataract surgery with IOL insert, 1 stage: 17 percent (ophthalmology)
  2. Upper GI endoscopy, biopsy: 8 percent (gastroenterology)
  3. Colonoscopy and biopsy: 5.7 percent (gastroenterology)
  4. Lesion removal colonoscopy, snare techniques: 4.4 percent (gastroenterology)
  5. Injection foramen epidural lumbar, sacra: 4.1 percent (orthopedics)
  6. After cataract laser surgery: 3.9 percent (ophthalmology)
  7. Injection spine: lumbar, sacral (caudal): 3.6 percent (orthopedics)
  8. Diagnostic colonoscopy: 3.6 percent (gastroenterology)
  9. Injection paravertebral: lumbar, sacral: 2.2 percent (orthopedics)
  10. Injection foramen epidural add on: 2.1 percent (orthopedics)
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