From losing $700K to a regional super group in 4 phases

How we took this group from losing $700K to a regional super group in 4 phases

[Note: This case study is real in every aspect. Names and location have been changed to protect client confidentiality.]

 

The year was 2012. Business was rough for Dr. Mizo’s group of five gastroenterologists on the east coast.

 

Just the previous year, they lost $700,000.

 

That’s when we were referred to, by another gastroenterology group that we now have been serving for 9+ years. To consult first and explore if we can figure out what was wrong.

 

“We have been using NextServices for over 9 years. The initial transition was made very easily from our old system to the new Practice Management System. There was training involved and the staff was very professional in helping everyone understand (the system in the initial phase).”

DR. MIZO'S TEAM

Our analysis unearthed a few problems:

 

• A huge backlog of outstanding claims from months ago
• Routine untimely claim submissions!
• High denials for authorizations due to non-participation with major insurances
• Billing staff was not savvy with current coding guidelines
• Billing system made claim submission time consuming and offered limited management control

 

Dr. Mizo and his partners figured they needed our help to get profitable. Little did they (or we) realize that that first step would lead them to become a super group of gastroenterologists in the region. In just a few years.

 

Here are some specific results:

 

• Collections increased by 117% within the first year
• We recouped $250,000 from old A/R within 3 months
• Generated additional $125,000 within 5 months via a process to collect patient payments upfront.
• We tracked their Meaningful Use compliance. This added $220,000 in incentive payments.

 

Year 1 collections

 

Here’s the backstory.

PHASE #1 /
From loss to profits by fixing the source of billing problems

The reason that you struggle with revenues as a medical practice is because your practice responds to outcomes.

When payments drop, you look at A/R.

 

When patient volume drops, you worry about attracting new patients and reaching out to referrals.

 

In reality, problems start right in the beginning.

 

At the front desk, when wrong patient information is collected. Or, when claims are submitted without checking insurance eligibility.

 

That’s exactly what we did for Dr. Mizo’s group. We fixed the small leaks through the billing cycle. Starting right upfront.

 

Patient insurance coverage. Benefits verification. Procedure authorizations. Outstanding balances (at least two days before the appointment date).

 

We backed our analysis with thorough research. By reviewing 10,000+ EOBs.

 

This helped us understand payment patterns, denial trends, and reimbursement rates.

 

Through simple observation, we suggested changes at the practice. From scheduling to patient check-in to claims submission.

 

Together with the doctors and administrators, we worked on cleaning up the entire billing cycle.

PHASE #2 /
Stability by streamlining the billing cycle

The group had a huge backlog of pending claims. The challenge was to regulate current accounts receivable (A/R), while working on pending A/R.

They did not have the tools to differentiate paid, outstanding, and actionable claims.

 

First, our priority was to streamline payments. Regular flow of revenues was crucial to the group.

 

Second, to build strong billing systems. Timely submission of claims. Accurate quality checks. Verifying patient coverage information. Structured A/R follow-ups and management of denials.

 

We moved the group to a cloud-based billing system (AdvancedMD). As a preferred partner, we get better rates and pass the benefits onto our clients.

 

AdvancedMD provided greater control and billing transparency.

 

Third, we began verifying insurance contracts to determine reimbursements rates of the group.

 

With some TPAs, we were able to negotiate contracts at 300%. The global agreement added $400,000 in revenues.

 

Fourth, we set up ERAs/EFTs with all major insurances. This automated payments and reduced turnaround time. The doctors began to see money quickly.

 

Fifth, the group received patient eligibility and benefits reports 5 days before appointment. This reassured the doctors that they would get paid for their services. Separate teams started working on old and current A/R.

 

The group recovered $250,000 within first 3 months from old A/R.

 

Finally, timely claims submission is necessary for optimizing revenues. We began submitting claims within 24 hours. All claims had to pass two tier quality checks. This ensured high first-pass ratio.

 

Same day denial management coupled with regular follow-ups helped streamline insurance A/R.

 

In the first 5 months, the group managed to collect $2.5 million. More than they had in several years.

 

For patient collections, we setup upfront collection process. This generated $125,000 in revenues within first 5 months.

“NextServices team is very knowledgeable. They make sure that they follow all the guidelines needed for filing claims to the many insurance companies in a timely manner.”

Other results after streamlining billing:

 

• Overall insurance A/R for the center dropped by 27%
• A/R days reduced from 39 days to 25 days
• Overall collections improved by 23% year on year

 

 90+ A_R Graph

PHASE #3 /
Navigating compliance by tracking and winning audits

The Meaningful Use program provides incentives for using a certified EHR and demonstrating compliance. The program also penalizes for non-adherence.

The program demands accurate measure tracking and demonstration of compliance. It also requires submission and attestation of compliance data to government registries.

 

The group was eligible for enrollment in the incentive program under Medicare plan. But did not have the time or resources to track individual provider data. The nuances of data submission also proved to be challenging for the staff.

 

Our compliance specialists took over tracking physician performance.

 

We provided detailed performance reports with tracking of individual measures. Suggestions on improvements helped physicians course correct and meet compliance thresholds regularly. We also attested for the group and submitted compliance data to government registries.

 

As a result, the group received $220,000 as compliance incentives (over a 5 year span). Everything was working as intended..

 

Until..

 

Centers of Medicare and Medicaid Services (CMS) audited Dr. Frank’s submissions. CMS withheld the physician incentives and demanded further proof of compliance.

 

The doctor was at the risk of losing financial incentives. And up to 4% of reimbursement cuts across all Medicare payments.

 

We reviewed the auditor’s requirements. Based on the requirements we began compiling documents to build a strong case.

 

Certified EHR Technology license and vendor agreements proved the use of a certified EHR. Security and risk assessment reports demonstrated compliance.

 

We contacted specialized case registries to gather supporting information for individual measures. And double-checked compliance data.

 

As a result, Dr. Frank passed all measures. The audit was reversed. And the group received complete financial incentives.

 

CMS physician audit selection process is random. From time to time, the agency selects a handful of physicians for an audit. Having selected once, risks selection again.

 

In 2015, the group was audited again. This time for two group physicians. Through experience and accurate documentation, the group navigated this audit as well.

 

“Once you implement whatever billing policy you want in place it is followed by all. If there are questions regarding any patient they reach out to us via email to try to get things done efficiently and quickly.”

PHASE #4 /
Expansion from group to regional super group

By this time (in 2015), the group was prospering. Operations were good and revenues were consistent. Allowing the doctors to focus on expansion.

It was time to become a super group.

 

By merging with our other clients – the gastroenterology group that originally referred us to Dr. Mizo. As both groups used our services they looked to us to make the transition smooth. Mergers of this scale have significant implications for billing.

 

Next, we initiated and completed credentialing for all top insurances. Our team worked with the practice management software vendor to merge billing records of both groups.

 

We negotiated for higher reimbursement contracts and also helped set up operational policies. This ensured streamlined billing updates and avoided overlaps in administrative processes.

 

Today, the super group enjoys the benefits of the merger by saving costs and a streamlined process.

“In all these years I have had the pleasure of working with really professional team leaders. Whenever I need anything done there is usually a key person that will be able to help with any issues.”

Summary

We took the group through 4 phases:

Phase 1: Loss to Profitability
Phase 2: Stability
Phase 3: Navigating Compliance
Phase 4: Expansion

Each required a different skill. From us and them. Today as a merged entity, the group is looking for further expansion to redefine gastroenterology organizations as we know it.

“Recently we merged two offices into one system and it is working flawlessly. We began by conducting risk analysis. The goal was to identify all possible areas for payment disruption."

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