2. Robert E. Goff
Formerly Executive Director & CEO University Physicians Network (UPN)
Robert has over 40 year of experience in the healthcare industry, a significant portion of that with physicians, independent physicians, on
strategies to improve their practices, and to allow them to survive in the changing environment.

3. Official Disclaimer
The information presented is for general information only and are not meant to substitute
for legal advice. Always seek the advice of an attorney on legal matters.
Legal Guidance
Copy righted © material is subject to fine of $5000 per occurrence
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4. 04
Fix leaks in your Revenue Cycle to increase revenue
Since payers aren’t going to pay more, find it yourself
– in your own practice
Where can you find added revenue within?
• Copays & deductibles
• Inaccurate coverage verification
• Services not billed
• Under billing
• Money lost on the margins
• Bills lost to timely filing
• Lost opportunities to correct and re-submit billings
• Lost opportunities to appeal
• Insurance underpayments
• Not disputing retractions

5. • Collect them at the time of service
• Verify eligibility of all patients coverage
• Not a guarantee
• Obtain a credit card to guarantee
• Require a credit card at the time of
service to guarantee coverage, and
eligibility
• Invite patients to express concerns about
payment, and work out payment plans
Average physician has 3000 office encounters
annually
At an average of $30 per co-pay = $90,000
Cost to bill - $5-$7 each
The loss if you miss 10% a week - $9000
Average deductibles are now $1800
Most patients are responsible for the full fee
Cost to bill - $5-$7 each
33% - 40% of non- elderly adults have
outstanding medical bills – avoid making your
one of them
Leaks in your copay & deductibles collections
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6. • Integrated EHR & PMS largely recaptures
these billables
• In hospital services – maintain a listing
of all patients currently hospitalized, and
have physician confirm their visit, when
at hospital upon daily return to the
office
5% - 7% services are never billed out
Procedures in medical record that are not
carried over to the super bill
Hospital visits not reported back to the office
Bill for everything that is done
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7. If you get paid 100% of what you billed – you
may be leaving money on the table
• What fees do you bill out?
• Bill U&C or plan fee allowance?
• Bill U&C
• Plans pay the LOWER of the amount
billed or the allowable fee
If you don’t fill in the dollar amount on the
claim, you will be paid -0-
If you don’t fill in the number of unites on the
claim,
Money on the margin
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8. • Do not batch bills – send daily
• Improves cash flow
• Reduces lost claims for follow up
• At day 30 go to payer’s website and verify
status of any claims 30 days old that have
not been acted on by payer
• If not in their system – bill again and
follow up to assure receipt the next
day.
• Make sure that the claim has been
received by the plan
• Remember:
• Sent does not qualify
• Proof of receipt is required
• Payers own data – web site
• According to the AMA 17% of all claims are
denied for timely filing
•
YOUR #1RESPONSIBILITY
Get your bills out
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9. • Learn how to read an EOB
• Checking your claims daily means that
you are identifying a status problem at
30 days.
• If a claim is rejected – fix and resubmit
pronto
10%- 30% of all claims are rejected
5%-15% of revenue is lost because 50% of all
rejected claims are not re-submitted
Understand, Correct And Resubmit Rejected Claims
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10. • A claim Not appealed is a claim
definitively denied.
• It is not that hard to send an appeal
• Read the EOB, understand the why?
• Appeal Letter:
• This practice is appealing the denial
of the attached claim. Your denial
claims that this practice failed to……
• You are incorrect, proof is attached.
6%- 14% of claims are denied
50% of denials are never appealed
70% of appeals are successful
Be Appealing
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11. • Most practices use 20-30 codes – learn
that you need to document them to
support your billing
• EHRs with “Code Checker” features
confirm the sufficiency of documentation
to support selected coding level. (Services
must be appropriate to the Dx)
• PMS with Right Remit™ features will auto
audit against allowed fee schedule
5% - 10% of practice revenue is lost due to
the “chilling” effect of coding challenges
Physicians that are insecure in their
coding/documentation hurt their own
revenue by under coding legitimately earned
services.
6% of practice revenue is lost due to
payments less than contracted rate
Get paid What You Should
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12. • 6% of income is lost due to payers paying less than the contracted rate.
• That is an average – meaning that some practices are regularly being paid much less than
the contract rate.
Self Audits
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Audit yourself
Build an audit work sheet for each payer -monthly check a different payer incoming against your audit list
• Take your super bill
• If you can’t access the payer’s fees, build a chart over time using paid claims
• Compare them to what you were paid
• If under paid – appeal
• If in doubt - appeal

13. • Payers conduct post payment audits – and rend
letters claiming their practices have been over paid
• You must respond
• Your response should be a dispute
• Dispute letter:
• This practice is in receipt of your letter requesting a
repayment of xx. Be advised we are, in accordance
with out rights under the Federal Fair Debt
Collections Practices Act and applicable state
regulations disputing your allegation. Please provide
us with the following information to document your
allegation:
• Documentation that payment has been made to
this practice (copies of canceled checks)
• Certified copy of the fee schedule in effect at the
time of payment
2% of practice revenue is lost to post
payment challenges
Payers – often their commission
based agents – may even seek
recoveries when they are not legally
entitled to such funds.
“Just because NYS regulations say we
can’t off-set the money, that does
not mean we can’t ask for it back,
physicians are expected to know
their contract and the regulations”
Loran Firbush, Oxford Health Plans
Don’t Volunteer To Be A Victim
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14. NYS Regulations
•Retroactive terminations – While these should always be disputed, NYS limits the exposure to
120 days from DOS. No longer can they go back years to seek recovery of claims paid. (If
services received prior authorization)
•Authorizations can’t be withdrawn, if required for a service, and given, unless the patient is
not covered, or false information was relied upon in granting the authorization initially.
•Look back at paid claims is limited to 2 years from payment, unless suspicion of fraud or abuse
• Negative remits/off-sets; require at least 30 days prior notice. Time for the physician to
dispute, but you must read and act on your mail.
•Non-par physicians must submit claims within 15 months of DOS or the claims will be denied,
and the patient cannot be held liable.
Disputing Retro-Recoveries
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15. • In NYS: go to the NYS Office of the
Comptroller, Unclaimed Funds web site
• www.osc.state.ny.us
• Give them the social security number of the
physicians, and the Tax ID. Ask them to
search to un-cashed checks, refunds, or
other funds they may have and are been
turned over to the State as abandoned
property.
Once a year……
Send or look-up unclaimed funds from your
State office that collects them.
Recovering money from escheatment means
a failure in your accounts receivable
management
•How did this money get by your practice?
•Who wrote it off?
•What happened that these funds were lost?
Bonus Item Escheatment Recovery
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