Persistence and a good system can boost your payment rates

Here are 10 ways to get the money that slow payers owe you

You have heard it all a thousand times before from payers:

— "I’m sorry, we don’t have any record of receiving that particular claim."

— "I’m glad you called. We have some problems with the way that claim was coded."

— "You say no one returned your previous calls? That’s strange."

— "It looks like we’re going to need more information before we can authorize payment."

Health plans have always been good at finding ways not to pay providers. What’s more, "based on reports from practices across the country, the situation seems to be getting even worse," says Dave Gans of the Medical Group Management Association (MGMA) in Engle wood, CO.

"Many payers seem to be creating obstacles to cutting a check, hoping providers will just give up and write the bill off," says Heather Bossin, executive director of the Washington University School of Medicine, a St. Louis-based tertiary care faculty practice for more than 800 physicians at more than 60 sites.

One of Bossin’s main jobs is to oversee the Washington University Shared Billing and Collection Service (WUSBCS), one of the country’s largest centralized academic billing operations. WUSBCS’s mission is simple: "Get our receivables in and out fast, preferably within 45 days," she says.

When it comes to administrative and coding hassles with payers, on average about 10% of the school’s claims are denied, and another 20% end up in reimbursement limbo — neither rejected nor paid.

When confronted with a case of payer amnesia, "We don’t just write off an account simply because we haven’t gotten a response from the payer," Bossin stresses.

Here are 10 tactics these St. Louis providers and the MGMA recommend to get payers to respond when they put on the long stall hoping you will just give up and go away before receiving proper payment.

1. Tag and route unpaid invoices. WUSBCS routes its unpaid invoices through the IDX Paperless Collection System, which identifies target invoices and forwards them to the appropriate staff for action. Each receivable is sorted by major payer groups, allowing staffers to develop in-depth knowledge about each payer’s payment habits and working relationships with their plan counterparts.

Starting with that approach allows you to quickly get on top of which accounts need attention and give responsibility for the follow-up to specific employees.

2. Track your mistakes. The billing software’s rejection subsystem at Washington University tracks the volume of claims that are rejected or delayed due to departmental omissions or errors in registration and coding. That information is broken down by code and given to each department, which can use it to spot patterns by type of mistake and individual provider or coder.

"This kind of information helps us identify what and who needs training," Bossin notes.

3. Know when to fold em. If a rejected or denied claim requires action from the clinical department to be resubmitted, a request is sent to that department. If there is no internal response within 90 days, the charge is automatically written off to a special adjustment code.

Previously, billing would just keep resending such requests. Meanwhile, "the receivable would stay on the books. That’s an inefficient way of working," says Bossin. "Now, claims we can’t do anything about get written off."

4. Use internal consultants. Each clinical department is assigned an accounts receivable consultant. Smaller practices may want to use an in-house coder or biller to perform the same function.

Among the consultant’s duties are these: Prepare the department’s monthly claim reports, meet with staff to identify issues that delay reimbursement, identify specific late payers/types of services that are experiencing payment delays or denials, and help resolve accounts.

5. Follow up aggressively. Once a pattern of delays or denials has been established, WUSBCS follows a progressively more aggressive line of attempts to collect legitimate payment. A fundamental attitude to take in such situation is this: Don’t be afraid to go over someone’s head. For instance, Bossin’s staff start by talking with the payer’s line people. If the problem is not resolved, they move on to the director of billing operations. When contracting agents are needed to resolve the issue, they are contacted. If necessary, the provider’s lawyer gets involved.

"A lot of people hesitate to take it to the next step with payers," notes Bossin. "They don’t follow up with someone at the management level." It can be frustrating at times, but once payers know you’re going to be persistent, they start to realize they might as well go ahead and deal with you, she adds.

6. Categorize denials. When claims are denied or returned for information, the charges are posted with a code noting the reason the claim was returned, then they are sorted, prioritized, and routed to the appropriate staff specialist for resolution. Denied or returned claims for medical reasons — such as medical necessity or current procedural terminology issues — are sent to a special appeals team for resolution.

When setting collection priorities, "why work first on aged accounts that you have to research the reason for the delay when you have the reason already at hand?" she asks.

7. Set benchmarks. Each clinical department at the medical school receives monthly reports on its claims accounts. In addition to accounts receivable performance, the reports include the volume and aging of fatal edits (missing information) and automated request forms (ARFs) pending. ARF reports summarize the volume and aging of accounts that are pending requests for information. Those volumes are compared to prior periods, other clinical departments, and schoolwide averages.

This information is compared among departments and discussed at regular management meetings. "No one likes to be the worst in the group," says Bossin.

8. Monitor performance. All claims that remain in third-party follow-up files for a certain period of time automatically are rerouted to the unit supervisor to troubleshoot and to identify underperforming or undertrained staff.

9. Act. Employees are assigned a target number of invoices to act on each day. At WUSBCS, staff are expected to take action on 50 to 80 invoices daily. "If you follow up, you usually get your money after the first action," she says. "Accounts older than four months may have slipped through the cracks at first and possibly a second time, which is an indication of a different problem. You should hound payers; make it difficult for them to ignore you."

10. Collect. Those third-party collectors who collect from insurance companies are not assigned other duties, such as payment postings or refunds. They work exclusively in a specific payer grouping, such as Medicare, or government and commercial accounts. They learn the formal rules of their third-party payers, along with the unwritten rules and habits of specific departments.

"Some billing operations want each staff person to be a kind of jack-of-all-trades — post payments, appeal charges, and handle correspondence," says Bossin. In the process, however, collections can get pushed aside. "By placing a focus on our collectors, we can get them the training and mentoring they need" to do their best all the time.