Billing 101

The tools you need for managing your billing process to maximize cash flow.

Tricia Morgan Putt

Managing billing and cash flow begins with your clinic’s first contact with the patient. In that first call from a patient, the front office team should be setting the expectation for payment. You can create this expectation by having your front office team discuss payment options from day one by asking for billing information at the time of scheduling the first appointment or directing the patient to your website for “online” registration. Once your office receives the insurance information from the patient, it is important to verify those benefits and review them with the patient. As the year progresses, most patients have met their deductible, so this is an additional consideration and point to discuss with patients. Additionally, for Medicare patients, the office should verify how much of their cap/threshold has been used for the year. Once all verification has been completed, the front office team should review the costs of care with the patient. The patient should sign a form acknowledging the benefit verification. It is a good idea to add verbiage in the acknowledgement that the verification of benefits is only an estimate and not a guarantee of payment from the insurance company. All private insurance patients should pay their co-pay at the time of service at a minimum, if not also their coinsurance and deductible amounts due. If your office is not comfortable collecting co-payments at the time of service, your clinic is losing money. On average, a clinic that has monies paid before treatment will collect 90% of the co-payments. If a clinic waits until the patient is done treatment for the day, the clinic will collect an average of 70% of the co-payments.  If the clinic waits to bill the patient for 30 days, the rate lowers to 40%. As co-payments increase, the potential loss of revenue may impact your office significantly.

Tracking authorization is extremely important. If your office utilizes an electronic scheduling program, most are equipped with a tracking tool that can send automatic notifications. It is hard for a therapist to track these dates without some type of notification. The front office/billing person should start the authorization process well before the last visit, as authorizations usually take a week or more to process from the payer. Some insurance companies will not accept retro authorization requests, so it is imperative that you have a system to track and request on-time authorization renewals.

Finally! You are now at the point in the revenue cycle where you can actually bill for your visit. Your team has done all of the due diligence needed for a clean claim to be submitted. Most offices now submit a majority of their claims electronically. When you submit the claim within minutes or days, depending on your clearinghouse, you will receive an acknowledgement of acceptance or rejection of your claims.  For some clearinghouses, if one claim is incorrect (missing units, missing date of birth, missing patient address), the entire batch may be rejected. If this is the case, you need to fix the error and resend the entire batch. If your clearinghouse only rejects the items that are incorrect, most of the time the office is able to correct the item online and resubmit. This first level of claims editing occurs at your clearinghouse, then a second level occurs directly from the payer. A claim may have all of the correct information to be accepted by the clearinghouse, then go on to be denied by the payer for multiple other reasons. Some of those reasons may include exhausted benefits or the patient not being an eligible subscriber, for instance.

An office usually receives correspondence daily from various payers. The best workflow is to process all denials/requests for information on a daily basis. Many times the patient is still an active patient in your practice, and you may be able to inform the patient of the insurance problems at their next visit. For private insurance patients many times it is helpful to get the patient involved from the start to assist in mitigating payer problems. Many times the patient can call the insurance and have the issue resolved that day.

Tracking payment trends is crucial for survival in the payer vs. clinic world. Changes in payment can surface suddenly, for example, lower payments may start occurring due to a software issue. If you do not have a system in place to track these changes, then you can lose revenue that you deserve. Your first point of defense is your payment poster. This employee should review all your payments on a daily basis. They will be able to spot any aberrant trends in payments. It is a good idea for the payment poster to be familiar with all of your payer contracts, knowing every rule and coding edit the payer may follow. The payment poster should also be adept at reading EOB’s and be able to assess any changes. EOB review will also provide insight related to potential undercharging for a service. If your system allows you to bill by the contracted amount, it is important to build those values into your tables. If your system does not allow contracted amounts to be billed, then you should always take a contracted discount for the allowed amounts of your billing. If your allowed amount is the same as your billed amount, you may need to review your fee schedule.

Lastly, your office should have a check and balance of your staff productivity, not only for your therapists, but for your billing staff as well. Your therapists should have cancel, no shows and billing trends monitored on a monthly, if not weekly basis. For instance, do you have a therapist in your office who seems to have more canceled or no show appointments than the norm? Or worse, patients who just drop off the schedule? If so, do you know the reason? On the billing side, what are your average collections per month? Do you know when that number drops and do you know the reason why? The reasons could be because your visit number dropped the month before or entire batches of electronic claims were not processed. Whatever the reason, if you do not track it, you will not know where to start looking for “lost” monies. As an owner, it is hard to find time to work on the business side of your day; however, if you take time to review a few metrics on a weekly basis you will find that your feeling about an issue is either justified or not. Either way, by tracking your staff productivity—both front office and therapists—you will have the tools to fix the issue.

Tricia Morgan Putt is the owner and President of Integrity Reimbursement Inc. She can be reached at TMP@integrity-email.com.