09 Apr 2016

How did the frog make it to the mountaintop?


My dad frequently forwards some amusing emails. Today I got an email about a group of frogs that were given the challenge of climbing a mountain. Once they started climbing, several of them started realizing how difficult the task was. Some got scared. Some complained. Some said this was stupid. Some fought with the others. Some kept saying that this was an impossible task and they shouldn’t have agreed to climb this daunting mountain in the first place.

Slowly, one by one all the frogs stopped hopping – except one. He made it to the mountaintop. After he got back, everyone pounced him and asked him how was he able to climb this challenging mountain when none of the others could. At first he didn’t respond. Then he saw that the other frogs were trying to talk to him, he indicated that they wait, took out his headphones and said, “Sorry, what did you say?”

The moral of the story is to ignore negative thoughts and focus on the positive. If we don’t hear about others’ complaints or fears or are oblivious to them, we simply may be more positive about everything we do. I could relate to this story – whether it’s about climbing mountains or running a business, what I think about a task seems to matter more than the task itself. Last month, I climbed Mount Kilimanjaro, the highest point in Africa and if there’s one thing that mattered more than the body or its capabilities – it was my state of mind.

09 Apr 2016

Should you send patient statements daily or in bulk?


Before considering this question, let’s recap the process before it’s time to send patients a financial statement for the amount that is her responsibility. A patient is responsible for a service usually when her insurance pays nothing or a portion of the fees. Before a visit or a procedure, it’s imperative to check a patient’s eligibility and benefits. We find several practices/ surgery centers that do not have the bandwidth to complete this task and the practice management system is not equipped to complete this task automatically.

If that’s the case with your organization, sign up with independent eligibility verification services – remember that it’s never fully automated. Checking a patient’s eligibility decreases the risk of the claim being denied by insurance. After the service is performed, it’s important to submit charges within 24 hours of service – the longer it takes to submit charges, the greater likelihood that it may be denied. After receiving payments, it’s important to post payments in the practice management system immediately. It’s at this point when we know what a patient is responsible for.

The answer to the question above (should you be send statements daily or in bulk?) is simple: send them daily. At the outset, collecting money from patients after a service is one of the most difficult parts of the revenue cycle. It gets a lot more difficult to collect with every passing day from the date of service. Often practices make the mistake of sorting patients alphabetically and submitting statements in that order. This process does not take into account the amount in question or even the likelihood of getting paid from that patient. Ideally, a practice or its billing company must use analytics to determine the likelihood of getting paid and send statements accordingly. If a patient has gone through an endoscopy under a failed insurance plan then the patient must be made to pay the very day of service. Consider if a patient is a repeat offender or if she has occasionally lapsed. What type of insurance plan history does the patient have. While it’s the responsibility of the center to bill all patients, it’s also important to remember that not everyone will respond or even pay the same way. If she is routinely missed payments or ignored them, bill immediately. The administrator or system must determine this as soon as a patient is provided service – this decision must extend through the process and trigger a statement and type of statement once payments are posted.

In summary, it’s important to think about the process around patient accounts receivable differently and not treat all claims and all plans equally after a point. It’s also important to work on statements daily and send them. On a future blog post, I’ll explain methods of sending statements and what must happen after a statement is submitted – when and whom should you be calling?

By Praveen Suthrum, President & Co-Founder, NextServices.

09 Apr 2016

5 Things to look for when reviewing billing of a surgery center

When I review billing of an ambulatory surgery center, here’s what I mainly look for and it usually gives me enough clues to what I need to know.

1) Are there unbilled charges from more than a month ago?

2) How many denials show up in the EOBs received from Medicare and BlueCross for the previous week? I tend to review ALL the EOBs.

3) What’s the comparison of new patients to existing patients over the past year? What types of insurances do they represent?

4) How does the Accounts Receivable Master look? How many high-dollar claims (e.g. above $1,000) are untouched – over 90 days, 120 days and so on?

5) When were the contracts last updated?

There are several other things that I could look for and I do but at the outset am looking for a feel of how a center is doing. Answering these five questions usually provides me with a direction to probe more. I supplement these with interviews with staff. Another important activity that I do is to simply sit by the front desk and observe patient flow and work flow through the day – sometimes for several minutes at a stretch.

Taking the above steps, we turned around a gastroenterology center at one of the major hospitals in New York.

By Praveen Suthrum, President & Co-Founder, NextServices.
09 Apr 2016

How does the auditor deny claims?

They are the scrutinizers. The claim sniffers. They are the auditors. Have you ever thought of why your claims are denied or paid? Is there a really smart computer or a human face behind that hits to go or the no-go button? It’s both. When you submit claims, they go through some really intelligent computer programs. These programs process each claim and flag irregularities. These red flags are then extensively analyzed by claim auditors.

Traces an auditor looks for.
Auditors compare the submitted claims against quality benchmarks that insurances set. These include claims coding analysis, modifier usage analysis, insurance and regulatory compliance, visit and health record documentation. Alternatively, they look for trends. For example, a frequent trend is duplicate claims submission.

Consequences of audit.
If any discrepancies are detected, auditors deny the claim. In cases where payments have been made, recoupment follows the audit.

Recommendations by auditors.
1. Follow ethical coding guidelines while submitting the claims.
2. Take into account the compliance guidelines laid down by the insurances.
3. Avoid malpractices for higher reimbursements.

As an auditor, before hitting the pay button I think of denial. I look into all aspects – coding, billing, eligibility, benefits and most of the claims have some or the other loophole which helps me deny the claim. I have always been taught – its your check book & you are making the payment on claim.
– Anonymous auditor (name withheld)

09 Apr 2016

5 insights from your EHR data

Statistics show that over 50 percent of all medical facilities have successfully transitioned towards implementing an electronic health record system. While implementing EHR may mean streamlining operations and going paperless, the process tends to become mechanical and many look at it as mere data entry over time.

Practices are unaware of the enormous amount of data they produce every day. Capturing vitals, physical exams, systems reviews and checking/prescribing medications are all forms of generating data. Typically, an EHR is an archive of data which, if used to its potential, can lead to interesting insights.

Here are five insights you can acquire with your generated data:

1. Population breakdown: The analysis of patient type that forms your patient pool. It is the means for distinguishing your patients as per gender and age. Mapping your patients against their corresponding BMI values helps to track how healthy (or unhealthy) your patients are.
2. Diagnosis chart: The top 10 diagnosis among patient population. This will help determine the most and the least occurring conditions.
3. Condition number: The number for patients who have less than or more than two medical conditions.
4. Drug report: A report of the top drugs prescribed by you and the drugs that required the most substitution.
5. Risk profiles: Maintaining risk profiles of your patient population and sorting patients based on low, medium and high risk profiles. The patients falling in the high risk pool may need a more personalized medical approach.

Healthcare organizations are pushing towards risk-sharing payment models where reimbursements are tied to quality of care instead to quantity. By adopting EHRs, we may just be scratching the surface of something bigger in the years to come. Technology will continue playing a greater role and having analytical insights will empower precise medical judgments.

09 Apr 2016

Is Your Center Checking These Today?


A claim can be denied even before a patient is seen by the physician. Essentially, the revenue cycle begins when a patient calls in to schedule an appointment. As simple as it may sound, the primary cause of most pre-visit denials is the lack of a checklist. What we don’t find in centers after centers, is the execution of the following list before every patient visit:

1. Is the patient eligible?
2. Has the insurance authorized for this procedure?
3. How much co-pay is due for this visit?
4. How much in deductibles will this patient have to pay?
5. Is there a past balance?

Checking off each activity off the list can significantly help reduce denials. Common excuses for practices to detour the process are “We do not have to do it for all the patients” or “We have a huge patient volume, this is impossible”. Due to the lack of this pre-visit process, surgery centers and practices have suffered in terms of growing denials and backlog in patient receivables.

The process can look more or less like this – say, a patient calls in for an appointment; the front desk can schedule the appointment considering physician’s schedule and vacant slots. Get eligibility for scheduled the patient done at least 2 days in advance and authorizations at least 5 days prior to the date of service. Hence, less confusion at the time of service. This can be done online or by single phone call to the carriers. Front desk can inform the patient about past liabilities at the time of appointment scheduling and collect the balance upfront. This helps to contain patient receivables.

Implementation is vital as it makes way for a more efficient practice. It is less hassle for the practice to chase down denials and receivables and for patients who have to pay up for non-covered or non- authorized procedures.

09 Apr 2016

11 reports to ask from your biller


Presenting a collection of reports that form benchmarks for practice performance. These are a standard set of outlines that you can ask from your biller and are crucial for measuring and tracking practice growth.

1. Established vs. New patient visits: A comparison report of new and established patients at the practice. Compare it with other physicians in the group or monthly/quarterly numbers for solo doctors. If the numbers are very different then identify the reason and fix it. It can be evidence of mismanaged schedules or poor patient satisfaction.

2. Missed appointments: List of all patients who missed appointment without prior notification. Missed appointments without prior notice is costly for practices. Ask for a report weekly to identify the number of missed visits. Efforts should be concentrated to reduce the number overtime.

3. Open claims: This is a report for claims that have not been submitted to carriers due to some missing information. Patient’s insurance information, eligibility, authorizations are some of examples of missing information. Identify the open claims. Reconciliation of open claims in a timely manner would ensure everything is billed without anything left on the table.

4. Account receivables: A report of money that is owed to the practice from insurance and patients. Industry standard points towards keeping 90+ insurance receivables under 20%. Ensure most claims are in the recent 30 to 60 days of claim cycle. Setting protocols upfront patient collections and appropriate follow-ups help contain patient receivables.

5. Quality control reports: A report of submission accuracy, number of errors (billing and coding). Scrutinize claims before submitting them to carriers. Study the report to track improvement in accuracy.

6. Charges vs. payments: The analysis of the total charges billed and the corresponding reimbursements received over a definitive period. This report can be used for weekly, monthly, quarterly and yearly analysis. It helps in determining practice progress over time.

7. Procedure volume analysis: The count of all the procedures performed at the practice – the most and the least procedures done.

8. Procedure billing analysis: This report can help you determine the total charge amount submitted to carriers for each procedure. By analyzing the corresponding reimbursements, which procedures got the highest reimbursements can be determined.

9. Facility analysis: The count of total patient volume across different facilities/locations and the charges billed from each facility. By asking for this report, which facility has the most patient volume can be determined.

10. Payor-Mix charges: The break up of all the top carriers and their charge amount.

11. Payor-Mix payments: The break up of all the top paying insurances.

09 Apr 2016

Satisfied Patients Keep Coming Back


Patient-centric healthcare delivery is the most important aspect of delivering quality healthcare. Thanks to advanced technology, patients are now more informed and want to be involved in their health planning and decision-making. The new regulations (e.g. MACRA, Patient Protection and Affordable Care Act) point towards value-based care and patient satisfaction. Unfortunately, patient-provider encounters have become mechanical. Exceptional providers genuinely care about the well-being of patients. Patient experience is just as vital as the billing process itself.

Let’s see why is it important:

Patient Retention

Patients satisfied with the experience will return. The quality of healthcare delivery, the hospitality, the treatment and the communication–they all constitute the experience. The physician’s ability to establish a strong connection with patients results in them returning – and thus revenue growth.

Effective Free Marketing
People believe in authentic and positive experiences. Satisfied patients will talk about their experience. It is much easier to get new patients through word-of-mouth marketing than it is by conventional methods. If a patient talks to a primary care physician about how pleasant his or her visit was with a specialist he had been referred to, the chances of getting more referrals increase. Eliminating negative experiences by focusing on patient engagement and satisfaction are crucial for growing your referral base.

In order to achieve higher levels of patient satisfaction, practices must be able to measure and analyze their current state of operations and determine areas needing improvement, as perceived by patients.

Here are some tips:

1. Conduct satisfaction / feedback surveys. Ask patients to take the survey at the end of each visit. The scores paint a clear picture on how pleasant (or unpleasant) the visit experience was. It will also point toward possible areas of improvement.
2. Encourage patients to rate your practice online via portals, such as Healthgrades or Vitals. This method creates trust and increases your credibility as a physician.
3. Train your staff to be polite and welcoming with patients. Make sure they are being helpful and respectful at all times.

The process of measuring and analyzing will naturally enable practices to increase the quality of the medical services delivered. This understated benefit of a patient-centered operations strategy is a powerful advantage for any healthcare system and tremendously contributes to the advancement of the healthcare industry.