On July 8 2015, CMS released the 2016 Medicare Physician Fee Schedule proposed rule which, if finalized, would drastically cut reimbursement rates for colonoscopy and other lower GI endoscopy procedures. Can your afford such cuts? Whether or no1t the proposed reimbursement cuts take effect, gearing up for the worst case scenario is the best way going forward.
Here are three tips that will help your practice plan better should the cuts be implemented (or not): 1. Same day claim submission: Many ambulatory surgery centers and specialty practices have specific days in a week when claim submissions happen. This results in an overwhelming number of claims pending to be submitted. To catch up with the piling claims, practices often resort to a rush job with lack of quality checks, not following billing guidelines, resulting in a growing number of denials. As a result, they face uncertain reimbursement patterns. Set an internal benchmark of clearing claims within 24 – 48 hours of the date of service.
2. 90+AR at 5%: Accounts receivables is mostly where the money lies. As with same day claim submission, also resort to same day denial management. Take relevant action on denials as soon as they occur. This is your best bet to get accounts receivables under control. Aim for 90+ AR to be at 5% to avoid reimbursement disruption.
3. Accurate medical documentation: At the onset of reimbursement cuts, it becomes extremely crucial that each claim be processed and paid accurately. On many occasions insurance companies ask for supplementary medical documentation prior to processing the claims. Adopt case specific documentation methods vs. templated approach. The benefits are twofold – the turnaround time for such claims to get paid is relatively less (as there is no back and forth with the carriers on missing/incorrect documentation) and it establishes your practice as a place for getting patient centric medical care.
The above tips can help optimize operations irrespective of reimbursement cuts. Not only does the payment cycle becomes more predictable, but also, provides clarity on the overall health of the practice. Have suggestions of your own? Let us know in the comments below.
According to a 2014 physician survey, 58.2% of physicians have worked between 41-60 hours a week. When in the business of providing care to patients, physicians are the most critical aspect of the business. Putting in more hours week after week ultimately results in a plateau phase. The productivity gradually decreases hurting reimbursements and physician status quo.
Here are six simple productivity hacks to avoid a burnout:
Each case is different. When seeing a volume of patients, majority of energy goes into determining diagnosis, course of treatment for patients. Focus on a single case at a time without worrying about the previous or the next patient or the number of patients. Focus on the quality vs. quantity.
2. Right people for the right job.
Let go the notion doing everything by yourself. Invest in people. For example, a good MA will make preliminary examinations, an administrator will scrutinize administrative processes, the front desk will take care of the visit related tasks and so on. Right people will know and enjoy their jobs saving you time to concentrate on care.
3. Train staff well.
As any business proliferates, there is a constant need to improvise internal processes and effectively realign with the current. Same is the case with healthcare, there are reforms pushing towards technology acceptance, billing and coding changes every year, it is very important that you and your staff stay in sync with rapid changes. Arrange group training sessions to ensure a continuous learning cycle.
4. Limit your procedures.
A consultation is different from a colonoscopy. Put a cap on the number and type of procedures you are performing each day. This will help you provide quality procedures and also accommodate consultations.
5. Control your work hours.
Now you have prioritized your tasks, have the correct people, you are functioning with a well trained staff and you exactly know the number of procedures, therefore have a much organized operational workflow. As much as possible, stop pushing for more and more work hours. This will help you establish a work-life balance.
6. Adopt technology.
Use technology and process automations wherever possible. For example, invest in an EHR that integrates billing and analytics, use patient portal for patient engagement, automated schedulers that allow patients to book their appointments based on vacant slots and their preferred time.
Have some productivity hacks of your own? Let us know in the comments section below.
Increasingly medical practices are getting concerned about their reimbursement models. New reforms including the plans offered under health insurance exchanges are expected to provide reimbursement rates close to what state Medicaid programs pay. In a space where reimbursements drop every year, it’s becoming extremely difficult to run a sustainable healthcare organization. Facing such pressure many small to medium medical practices and ambulatory surgery centers are considering getting acquired or merging with bigger organizations. But this may not be a viable option for all the centers and hence it becomes extremely important track reimbursements and ensure nothing is left uncollected.
One aspect to look at is, whether you are getting reimbursed at the optimum allowable rates by your insurance carriers. Underpayments can often go unnoticed and cause lasting effects to your bottom line. It’s fairly straightforward process and spending time tracking your payments will be worthwhile down the line.
Follow this step by step guide and get started with determining those under payed claims.
Determine the top procedures and consultation codes- Ask your biller to provide you the top fifteen most performed procedures and consult codes.
Confirm the agreed upon rates- It’s not possible to determine underpayments until you know how much you are supposed to get paid. Verify your contracts or ask the insurances you are participating with, to provide the fees schedule for fifteen most performed procedures. Fee schedules for Medicare and Medicaid are publically availablehere. Commercials may take time to respond but with regular follow ups, will eventually process your request.
Cross check the reimbursement rates– With the fee schedules provided by carriers, cross check each claim against the reimbursements stated in the fee schedule.
Flag discrepancies– Build a process to identify underpaid claims regularly. Create automated scripts or partner with companies to review each check, electronic payment and remittance advices on everyday basis. Flag the discrepancies and have your accounts receivables team work on such claims the same day.
Appeal on those claims– For historic claims, send appeals to carries with a copy of the fees schedule. In cases where carriers adamant on not reimbursing correctly , speak to the medical director on the carrier side and aggressively pursue correct reimbursements.
Check for opportunities of negotiation– While revisiting your contracts, check when was the last time you negotiated on reimbursement rates. Most commercials allow for contract negotiations every three years.
While practices do and should spend the major portion of their time providing quality care to patients it’s equally important to keep a tab on internal processes. If reimbursements fall then sustaining the business will become difficult.
Running a successful ambulatory surgery center is tough. From managing costs to tracking metrics to ensuring smooth flow of revenues.
An optimized billing cycle results in a regulated reimbursement cycle.
A more basic and often neglected aspect of the billing cycle is the lag days analysis. Most centers are unaware of the lag between the date of encounter to actual claim submission. Lag days lead to an uncertain revenue cycle.
Problems with an uncertain revenue cycle.
1. Revenue prediction becomes difficult.
2. Revenue cycle is never standard.
3. Identification of problem areas becomes strenuous.
Tackling lag days.
Ideally, submit all claims within 24 hours of the date of service.
If this isn’t happening, there are only two possible scenarios:
Either physicians are not completing their charts on time or the claims are not sent on time.
Here are six quick tips to manage lag days:
1. Try to complete encounter documentation while you see patients. For consultations, enter the consultation and diagnosis codes during or soon after the visit. For procedures, aim to complete all encounter documentation immediately or before the end of day.
2. Make most use of technology. Invest in an EHR/practice management software that integrates billing. Using a mobile solution can help you complete billing on the move.
3. Customize encounter sheets or EHR modules to match your style of work and lower the time spent on each case.
4. Automate the billing cycle wherever possible. Use OCR software to extract relevant text from scanned encounter sheets. Couple it with custom automation scripts to document CPT and ICD codes within an EHR/PMS.
5. Use a rules based engine for quality. The engine cross-checks all claims with coding guidelines for compliance.
6. Use a real-time eligibility tool to verify coverage details before and at the time of service. This activity will curb charge lag due to missing coverage and benefits.
Establish benchmarks on the acceptable lag limit for submitting claims. Maintain and track the lag day report and work on efficiency.
Reimbursements depend on the number of clean claims submitted to insurances, hence the count of claims that go out of the system everyday becomes an important number to track. Many centers tend to overlook this number and so there is no way for them to be certain if all claims go out of the system. This is a more serious problem than it seems, because physicians spend time, energy and resources seeing patients and missed claims eventually result in loss of income, a bloated AR and dissatisfied doctors.
Here are three steps to ensure effective claim tracking: Missing Claims Log
At the end of each claims submission cycle, the billing staff must run a report from your practice management system of all the claims submitted to insurances. Cross verify the number with the total patients seen for that particular cycle. Both numbers must match. For example, if your billing report indicates that 170 claims were submitted for a certain date of service, then 170 should be the number of patients seen on that date. Any discrepancy with the number will mean that there are claims that have been missed.
Open Claims Log
There might be instances when a physician may forget to digitally approve a particular visit or she may have saved the claim as a draft in an EHR and forget to submit. If using paper charts, your billing teams receive a batch of claims with missing information on a particular chart and decide to keep it on hold. It is important to keep a track of such claims. Deploy a detailed open claims log and have your billing staff document the occurrences of such claims. While reviewing the open claims take the necessary action to reconcile the claims. This ensures no claim is pending in the system.
Along with running reports for missing and open claims every week, run a ‘no show’ report for patients who missed their appointment during a week. Use these numbers to verify that no claims were missed and analyze trends over a period of time to reduce discrepancies between patients seen and claims submitted.
The alternative is to use good software that automates the above for you.
The healthcare industry defies traditional notions of supply and demand. There’s a lot of demand for quality healthcare services than there is to supply – more patient needs than there are doctors to serve. However, doctors ironically continue to worry about seeing more patients – perhaps, the type of patients with insurance plans that will suitably reimburse for their services. A major source of such paying services is from referring providers who refer patients and also from patients themselves who refer friends and family. Commonly, physician groups and surgery centers tend to see patients as and when they come (or as referred). But if they could analyze the source of where their patients are coming from then they might have deeper insight and therefore greater control over resulting cash flows.
Identifying top referring providers: Use your practice management system (or EHR) to run a report on all referrals during the past year or quarter (any measurable time duration). Examine the report to identify top 5 to 10 sources of referrals that cover 80% or more of your center’s patient volume (broadly applying Pareto’s 80/20 principle). Once you have a list that you can work with, we can develop a Referring Provider Value Plan.
An alternate way is to search your name (if you are a physician) or that of your surgery center using Treatment Tracker and look into the section of referring providers. It lists where your patients went before they came to you and where they go after you see them. This is your list to focus on.
Referring Provider Value Plan: A value plan focused on each organization that refers to you is important to help you give enough value for them so that they are encouraged to continue referring their patients. It must include the following information below. You would be surprised to get this information from your front desk and billing staff who could be talking to staff on the other side.
1. Basic snapshot of the organization’s work, key people (both physicians and staff), decision makers, whom do they engage with in your center, among your staff or those of your vendors.
2. Historical and present information on their patient volume, mix of procedures, their growth, market share (if it’s possible to assess), technology/ software used. Treatment Tracker gives information on Medicare patient volumes, procedure mix and so on – even this would be a good start.
3. Understanding how referring to you improves their patient health and therefore their referrals. What type of feedback do patients provide when they go back to the source? What information that you provide improves their ability to take care of their patients better? How clean and clinically pertinent is your operative note back to them?
4. What are their core needs as an organization? What are their key problems? Create a value chain that goes something like this: Physician Group X > Mainly serves n # of patients with stomach problems > Most of these gastroenterology patients see oncologist Y > m # of their patients work with Lab Z. Understanding this value chain (to the best of your ability) is important because it helps understand the value chain that your practice is a part of.
Your Offering: It may be difficult to think in terms of ‘offering’ being in the healthcare field but it helps to do so to keep your business in check. Identify in both qualitative and quantitative terms how what you do for their patients meets their core needs (from the value plan). For example, qualitatively by seeing the most challenging cases (patients) you are helping their brand perception improve. Quantitatively, you could be contributing to a return visit of say a patient that may contribute to $2,000/ year in collections, you could be contributing to referrals that a patient may bring, you could be contributing to downstream revenue. Can you compute the measure of your offering across a period of time (even broad approximations would help) – say during a quarter or a year? Sending this information periodically will help your referring providers understand and therefore appreciate the value you provide better. For example, by seeing 200 patients who may be contributing $2,000/ year back to the center/ practice, you could be contributing to $400,000 in collections for the center. Is there anything that you use that could benefit them (for e.g. your EHR)?
Seeing what you do as a physician in light of how your customer (in this case, a referring provider seeking your services for his/ her patient) will help you better present your services and therefore increase the likelihood of sustained referrals.
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.
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.
Since 2010, the ambulatory surgery center (ASCs) market has neither grown nor declined. ASCs start, shut-down and acquire other ASCs. There are over 5,400 surgery centers. Available physicians are limited and hospitals continue to pose a strong competition – sometimes partnering with ASCs. According to arecent Becker’s ASC article, ASCs will need to excel in a single specialty and run a very low cost center model to sustain in the future.
ASCs can further add plans that involve diet and exercise, virtual follow-ups for a monthly fee. This creates additional revenue streams based on deeper understanding of patients and their conditions. It also engages patients and their families better and brings them back to the center on a regular basis.
Outsourcing activities or tasks in a controlled and methodical manner is clearly a way to bring costs of administrative tasks down. Identify tasks that are lower on the complexity scale and delegate and outsource them. When they aren’t core to the business model (i.e., treating patients), tasks such as billing, coding, denial management, patient collections, accounting, credentialing, pre-authorizations and so on will tend to be distractions from the core focus of the surgery center. Outsourcing companies centralize operations for a large number of providers, giving them benefits of scale – these cost savings are typically passed on to the center that could then pass them on to patients.
According to the ASC Value Driver Survey, 24% of ASCs experience stable volume, 27% reported growing volume and 27 percent declining volume. In the same survey, respondents cited competition from other ASCs and hospitals as one of their biggest challenges. Clearly, it’s a time to focus and cut costs to stay competitive.