8 Quick Tips for Orthopedic Practice Revenue Cycle ManagementWritten by Laura Miller | February 17, 2012
Here are eight quick tips on revenue cycle management for orthopedic practices.
1. Recognize where the cycle starts. The revenue cycle starts as soon as the practice defines the terms of its relationship with an insurer — or the practice's policy regarding patients who have no healthcare coverage, says Tony Ryzinski, Senior Vice President of Marketing at Sage Healthcare. When the patient makes contact with your practice, the revenue cycle wheel begins to turn. The cycle's beginning includes stating the practice's financial expectations, collecting from patients without insurance and verifying insurance coverage and benefits from those who do.
Orthopedic practices historically viewed their billing offices as wholly separate units from the day-to-day activities of scheduling, registering, arriving and treating patients. This perspective comes from a time when practices routinely waited months for payment after providers rendered medical services. This state of affairs is no longer tenable in today's fast-paced financial world, an environment where medical practices' profit margins have grown ever narrower due to falling reimbursement and rising practice costs.
Operating an efficient revenue cycle requires practice wide buy-in to the following principles:
• Defining — and knowing — the terms of insurance contracts and establishing an appropriate but strict policy for patients without insurance.
• Involving everyone in the practice in the revenue cycle — clinicians as well as administrative staff — not just the billing office staff.
• Ensuring the accuracy of each data element about the patient — demographic, insurance and other information.
• Recognizing that the process of getting paid starts before the patient walks in the door.
Promote a broader appreciation of this final point — the process of getting paid starts before the patient walks in the door — by requesting schedulers to describe the practice's payment expectations to patients at the time they make appointments. Require them also to reiterate these expectations in appointment-reminder phone calls. Finally, mandate that time-of-service collection is a core function of front-office staff.
Developing a shared vision of where the revenue cycle begins and recognizing that everyone contributes to its success is the first important step toward a successful outcome.
2. Collect payment at the time of the appointment. Orthopedic and spine practices should collect co-pays from the patients before they leave the building, says Michael Franks of Physician Business Services in Tampa, Fla. "You won't see the money if the patient leaves," he says. "You need to have firm policies in place." To increase the chance of receiving the entire payment, a practice staff member can check the patient's eligibility before the visit occurs and then notify the patients of co-pays before services are rendered. The practices should also be able to accept credit cards for increased patient convenience, says Mr. Franks.
3. Update practice technology. There are several technologies orthopedic practices can adopt to improve billing and collections, according to Mr. Miller. Invest in web-based programs that standardize the workflow and check the claims for errors before they are billed because the web-based programs are constantly updated. "You want to find something that is fully integrated and has the modules to run the practice," he says. These functions should include billing and collections, patient information modules, charting capabilities and a scheduling module. "You want a core technology that is really solid and then you wrap coordinated processes around it."
Practice administrators should also pay close attention to accounts receivable. If a practice has a high percentage of claims not billed or on file, the surgeons are losing money on those visits. The appropriate technology can ensure all claims are accounted for and then make sure the claims are correctly coded before leaving the office. As a technology platform for Momentum Billing and their clients, Mr. Miller uses AdvancedMD, which, in addition to the modules stated above, contains a web-based claims scrubber that checks for faulty coding combinations and incorrect data fields before the claim goes out the door.
4. Double check to make sure payors process claims correctly. Insurance companies sometimes make mistakes, and they might even deny correctly coded claims. "About 12 percent of the time, the insurance company will not process the claim correctly, it should have been paid but now the only recourse is an appeal," says Nancy Moore, president of NBP, a practice management support company. "If physicians aren't on top of billing issues, money can fall through the cracks and just disappear."
Orthopedic practices should also be familiar with their rates from each payor to know whether they've been receiving full reimbursement. "We know what each of our clients is to be paid from their CPTs based on the contracts with the payors," says Dave D'Silva, COO at Healthcare Information Services, a company focused on maximizing physicians' reimbursement and revenue. "When payments come in, we compare them with the provider's contract. If the payment is incorrect, we go back to the payor, show them the mistake and ask them to pay the appropriate amount." In 2010, the company recovered more than $800,000 that was improperly paid by payors.
5. Have a process in place to correct denied cliams. When claims are denied, orthopedic practice staff should know exactly how to deal with them. Have a process in place to locate the mistake, fix the error and then have the claim back out the door quickly so denials don't bump against filing deadlines. "In some cases, when practices receive a denial there is no activity on it because the practice hasn't staffed someone to take responsibility for denied claims," says Mr. D'Silva. "You're leaving money on the table by not fixing or appealing these claims."
Incentivize your employees to meet national benchmarks. If the staff still has trouble, you might want to consider outsourcing denied claims to achieve the best returns.
6. Stay updated on new regulations and codes. It's necessary for coders to have updated training on coding changes throughout their careers to ensure claims are correctly processed. When it's appropriate, coders should also share updates with the surgeons to optimize their reports and cut down on extraneous work. For example, a surgeon who isn't updated on the codes might spend hours writing medical necessity letters to go along with the claims when all they need to do is enter a new code.
"With all the changes coming up, it's difficult to be an expert at coding and all-things-billing," Mr. Lau says. "But now, more than ever, it's about aligning yourself with people in the industry who do know what they are talking about and can best serve your interests."
7. Patch up leaks in information management. Assess practice processes and workflows for possible leaks in efficiency and develop options for fixing them, says Mr. Miller. If claims are often lost or denied, implement a system of checks and balances to fix these leaks in the process. One common problem in offices is the mounds of charts surgeons keep in their offices, says Mr. Miller. A standardized process should be developed to manage the flow of these charts. Another process that should be implemented in the practice is one that cross-checks and reconcile total visits and/or surgeries in a day against what was billed out. Miller has seen practices where up to 15 percent of their total encounters fell through the cracks and were not billed. It's important to delegate who is responsible for every aspect of the billing process to make sure it runs efficiently.
8. Leverage payor contracts to improve billing performance. To resolve the frustration of an insurer engaging in unfair payment tactics or creating inordinate delays, look to the contract, says Mr. Ryzinski. Shrewd negotiation during contract talks can make the document your ally. Ideally, the contract contains clauses that disallow bad insurer behavior — just as it will prohibit you or your practice from taking certain actions. Contracts with payors deal with many common issues, such as provider enrollment, take-backs and fee schedules. Keep tab on each payor's potential 'hassle factor' by creating a folder for each insurer. Staff can put copies of correspondence, notes and explanations of benefits revealing an underpayment or inappropriate denials into this folder. Retrieve the contents of these "hassle" folders to use at contract renewal to make sure frustrations with the payor are addressed.
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