Ensure Billing/Reimbursement is Maximized & Compliant

All providers in all specialties want to maximize their revenue, while maintaining compliant practices.  There are constant state by state, payor by payor, evolutionary changes in most areas of medical practice.  One of the challenges is to be able to keep up with these changes at all levels of the organization.You may have a collection of Stand Operating Procedures (SOPs) or employee manuals, which is a good starting point.  But how do you keep up?It requires not only an understanding of the changes, but also an effective mechanism for implementing these changes.When changes or vulnerabilities are identified, they should be addressed immediately.  You will want to ensure there is a mechanism in place to very quickly translate any findings into action items – updating any forms or reports; training staff all along the revenue stream on any corrective measures; determining if any retroactive corrective action is required; updating SOPs; etc.

Some ideas for how to keep up include:

External audits or reviews.  These provide an excellent starting point for reviewing potential issues with coding, reimbursement and compliance.  If there is an audit or review in progress, there is the potential to support a positive outcome (or mitigate a negative outcome).  If there have been adverse findings in prior external audits, it is important to ensure corrective action has been taken.  These also provide concrete examples useful for staff training.

Denial reviews.  Review of claims that have been denied are an excellent opportunity to identify and remediate revenue leaks.  Examples of findings from this exercise include (where appropriate):

  • not providing an unbillable service in the first place
  • improving documentation to better support medical necessity
  • updated forms, codes or other information or processes to ensure payment upon first presentation of claim, thereby improving cash flow and lessening staff time to process denials
  • identifying opportunities for streamlining appeals processes

Internal review.  There are a many variations of internal review, but an excellent opportunity to identify revenue leaks is to take a sample of cases from start (making an appointment) to finish (payment received and posted).  This process avails the reviewer of a glimpse into every step of the life of a service, and further allows for a time study aspect to identify any bottlenecks in the process, including any potential violation of state prompt payment laws by certain payors.

Contract review.

  • Identify any currently participating payors who may offer enhanced rates or be open to contract rate negotiations due to panel openings or deficiencies
  • Understand all fee schedule and reimbursement guidelines by payor (can lead to identification of additional billable services)
  • Identify payors who may be good candidates for network participation
  • Identify payors for termination of participation due to excess headaches or fees so low they don’t cover your costs

Most medical practices don’t have the resources to tackle these issues.  Either their staff is already overworked, they don’t have the Project Management skills to process and implement these changes, or the personnel dynamics are not conducive to these higher level changes.

Consider bringing in a consultant for these types of special projects.  We can tailor our projects to meet your time and budget.  Our consultations are complimentary, so give us a call today.

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