Keeping the cash flowing: 5 ideas to save time and money
Here are some ways to avoid claims delays and denials
It seems to be an increasingly common complaint: Despite efforts to submit clean claims to payers, practices are seeing more and more denials and delays of payments. Some of the problems are blamed on technology, says Layton Lang, MBA, chief operating officer at the eight-physician Dallas Surgical Group.
"We see a trend now that payers blame scanners or data entry people for mistakes," he says. "We might have a consult on the same day of surgery that is global, but if the initial time you evaluate the patient is broken out, it gets dropped. We’ve had to meet with plans to deal with this issue. That can be time-consuming and costly. Maybe it’s only $120, but if it’s a constant fight, it really starts to add up."
And it’s not just the denied and delayed payment that affects a practice, Lang adds, it’s the staff time and the increased salaries that practices have to offer billing staff to attract people who can deal with the constant stress. And as payers put increasing demands on practices to submit more and more paperwork, there is a higher likelihood of errors, further exacerbating the problem.
He says the hot job market also is affecting claims. Plans are hiring people with no experience, giving them a two-week course, and calling them claims adjusters, he says. "But these people don’t understand Medicare guidelines."
So what’s a practice to do? Here are five ideas that might help.
1. Define a clean claim. Lang says this might differ from payer to payer, but you should ask in each case whether a claim should be based on Medicare guidelines or some proprietary system. This information should be included in a contract from the start.
Pat Aalseth, RRA, CCS, CPHQ, a consultant in Albuquerque, NM, says it’s often the simple things that make claims unacceptable. For instance, if you have a conflict between the age of the person and the diagnosis, or if you get the gender of the patient wrong, payer computer systems will deny the claim automatically, she says. In another example, last October Medicare began requiring providers to include the full year — 1999 — instead of simply "99" in the claim.
"There are simple edits built into most computer systems now that will query something they think is wrong," Aalseth says. But beware that some conflicts may not be evident immediately, such as when the physician goes to a hospital to see a patient, and the hospital calls it an outpatient visit while you call it an inpatient visit.
2. Get approval when necessary. You also should be clear on what the plan’s referral protocol is, Lang says. "Some plans will say exam and treat, but we were really only supposed to examine the patient, and then sub-refer for something like a biopsy. Others say that the primary care physician has to circle the CPT code that the specialist can use. That is now illegal in Texas, but not everywhere."
Aalseth says it’s important for practices to get prior approval for any service requiring it. "That means knowing each managed care program," she says. "Write a cheat sheet if you need it. Many insurance cards also have some description of what needs prior approval, or they have an 800 number. Call and ask if you need to. And if they say you don’t need prior approval, document this, including whom you spoke to and what he or she said."
As rules and regulations change, you may even want to hold quizzes to make sure your billing staff knows them.
3. Know your department of insurance rules. Every state will have different rules, says Lang. For example, the law mandating which CPT codes a physician can use is specific to Texas.
4. Develop specialists. Lang says one key to avoiding problems is to make sure your front desk staff are adept at getting the right data from patients. "You have to know if a patient’s claim will go through an IPA, and if so, what the IPA rules are." You also should make sure staff know to ask patients if any of their insurance information has changed since their last visit.
Since it is impossible for one person to know all the rules, consider dividing claims by payer among billing clerks, says Elizabeth Woodcock, a Charlottesville, VA-based consultant for the Medical Group Management Association in Englewood, CO.
For example, one clerk could be devoted full-time to Medicare, another to Medicaid and workers’ compensation, and a third to the Blues and commercial insurers. By concentrating on just one payer, a billing person can better understand that payer’s rules and know how to work the system when problems occur. And by developing a relationship with the payer, billing clerks often can get to the right people more quickly and, in some cases, circumvent bureaucratic rules, such as restrictions on the number of claims that can be discussed per call, advises the American College of Physicians-American Society of Internal Medicine.
5. Pay close attention to filing time limits. For some HMOs, Aalseth says, that can be as little as 30 days. If you have a backlog, make sure you do the ones first that have the shortest limits. The faster you file a claim, the faster you get paid. Some experts advise setting a filing target of within three to four days after service has been rendered. Others prefer to file more frequently. Frederick Internal Medicine, a four-physician practice in Frederick, MD, files its claims daily.
"If I wait until the end of the week, I’m looking at 200 claims," explains Robin Laumann, the practice’s office manager. "If I file daily, there’s not as much paperwork. Instead of getting a check once a week from an insurer, I get checks daily. Our accounts receivable stays low."
It is not uncommon for as much as 25% to 30% of physician office insurance claims to be delayed, rejected, or simply vanish inside the black hole of an insurer’s payment office. And with so much practice revenue coming from insurance companies, cutting that percentage by any amount becomes increasingly important.