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Billing plugs That Pay Identify RCM Leaks


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Watch this Webinar to find and plug leaks in your earned revenue and educate yourself on how to optimize the efficiency and profitability of your practice.

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Billing plugs That Pay Identify RCM Leaks

  1. 1. 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.
  2. 2. 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 03
  3. 3. 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
  4. 4. • 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 05
  5. 5. • 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 06
  6. 6. 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 07
  7. 7. • 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 08
  8. 8. • 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 09
  9. 9. • 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 10
  10. 10. • 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 11
  11. 11. • 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 12 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
  12. 12. • 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 13
  13. 13. 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 14
  14. 14. • In NYS: go to the NYS Office of the Comptroller, Unclaimed Funds web site • • 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 15