Sunni Patterson is President/CEO of RMK Holdings Inc., a medical billing and revenue cycle management company serving physicians, physician groups and other healthcare organizations. Here she discusses ways spine practices can build effective, productive billing processes. 1. Know where your practice stands with its current billing system. The first step to increasing billing efficiency is to know where you stand, and then you can create a plan to reach your target. "Continually assess workflow processes, payor contracts, and training or knowledge gaps," says Ms. Patterson. "Monitor expected versus actual results then drill down to determine root causes of inefficiencies. Repeat." 2. Understand payor requirements. Stay on top of what each payor requires to achieve better reimbursement return the first time around. "Patients in general are shouldering more of their medical costs," she says. "This is especially true with spinal procedures because of increased payor restrictions, rigid guidelines and evolving reimbursement models. This means knowing the exact criteria for coverable procedures versus those that are not. If a contract term is vague or conflicts with another part of the agreement, address this with the payor early on."
3. Build relationships with payors. Ask someone on your team to build a relationship with your top payors. This individual should then create a hot list of key items per payor per condition that must be submitted including authorization forms/numbers, physician notes, expected outcomes and other documentation as applicable.
"Make sure this is gathered and tracked across the entire care team as applicable," Ms. Patterson says. "Implement a workflow process that will best facilitate collection of the required data and all related details on the front end rather than after the fact. This will benefit in several ways including proactive payor education, collaboration on how to build new revenue streams and identifying coverage changes early on."
4. Educate patients about the billing process. Engage patients with a heart to heart, in-depth pre-procedure financial consultation. "You and the patient should build a game plan for payment of any out-of-pocket costs," she says. "This will establish expectations and enhance patient relationships. Patients will be better prepared and educated when they receive their bill. Dig beyond insurance eligibility to let patients know their estimated obligation such as items that their carrier may not cover or limitations to treatment and remaining deductibles or co-pays. Then, assess their financial capacity to pay while identifying possible financial assistance resources in cases of hardship or other extenuating circumstances."
5. Take advantage of technology. Automate as much of your process as possible through efficient use of technology. Utilize payor specific online tools like real time eligibility and adjudication, electronic funds transfer and electronic remittance advice, denial management and coding edit applications.
"Better systems include the feature to create unique edits relating to your specialty, coding and/or payor terms," says Ms. Patterson. "When protocols are set, claims are flagged for additional action before submission. Spine practices should align and train their staff to prevent disengagement and encourage a collaborative environment. The key to maintaining a billing system that works for you is creating standardized processes that can be adjusted when necessary."
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