Ophthalmology and Optometry Coding Alert

Tip: Stop focusing on processes that won’t move the needle.

If your practice is like most eye care offices, your staff probably sat down at the end of 2019 and set goals for the new year — and in most practices, that means bringing in more revenue. To get your practice moving on that goal, it’s imperative that you focus on the right areas rather than wasting time in categories that won’t allow you to maximize reimbursement.

That was the word from the Nov. 20 Eye Care Leaders webinar “Maximizing Revenue with 4DX Accounts Receivable Management,” led by David K. Julien, MHA, CMPE, president of Alta Medical Management.

By prioritizing the factors that will allow you to bring in the most money, you’ll see higher cash flow over time, Julien said. He offered the following four tenets of the 4DX program.

1. Focus on the Wildly Important

The first discipline in the 4DX system is to focus your finest efforts on one or two goals that will make all the difference, instead of giving mediocre efforts to dozens of goals, he said. “These are the things that are really going to help move your business forward,” Julien said.

No practice is suffering from a lack of data, and there are always dozens of ways to manipulate the information to create reports, but you need to identify your wildly important revenue goals and then track those to maximize revenue in a compliant way.

2. Act on Lead Measures

The second discipline in the program is to apply disproportionate energy to the activities that drive your “lead” measures, and the idea of lead measures is that they are predictive (they lead to the goal) and they are influenceable — as opposed to “lag” measures, which are still important but don’t drive the business in the same way as a lead measure.

“If you just focus on the lagging measures, it’s like driving a car and only looking in the rear-view mirror,” Julien said. Instead, look ahead to see what you can influence to boost your KPIs.

“When my team gets together, we identify measures, and there’s a lot to pick from — not every practice will focus on the same measures,” he said. But to take an example of what his team focuses on, he looks at the following:

A) Charge reconciliation: “Ask yourself: Are we capturing everything?” You’ll track the percentage of clients where a foolproof charge reconciliation process is occurring each month to ensure that nothing is missing.

B) “Clean” claims rate: Are the claims as accurate as possible? This tracks the percentage of claims adjudicated without intervention (including clearinghouse rejections, payer rejections, and denials).

C) “Current” activity rate: Is every claim getting worked? This tracks the percentage of claims with a charge transaction, a payment transaction, or a follow-up note at least every 60 days. “This is not to say we wait 60 days to work these accounts — we set the follow-ups to happen when it’s appropriate for the payer,” Julien said. “For Medicare it might be 25 days, for example, or for worker’s comp it may be 45 days — but the expectation is that everything is worked at least every 60 days to determine what’s causing delays or issues.”

3. Keep a Compelling Scoreboard

The third discipline in the program is to ensure that everyone knows the score at all times. “We want to keep it simple, see it easily, make sure it’s accessible, mix lead and lag measures, and ensure that everyone can tell at a glance if we’re winning,” he said. This part of the process can include benchmarking the charge reconciliation, the clean claims rate, and the current activity percentage. “It was important to us to keep the clean claims rate north of 95 percent,” he said.

In terms of key performance indicators (KPIs), he aimed to have an insurance accounts receivable (A/R) percentage of greater than 90 days below 12 percent, with days in accounts receivable below 35 days. “Everyone wants their insurance collected as quickly as possible,” he said.

4. Create a Cadence of Accountability

This involves a frequently recurring cycle of accounting for past performance and planning to move the core forward, and includes a weekly “WIG” session — which stands for “wildly important goals.”

During these sessions, the team reports on the commitments from the previous period, reviews the scoreboard, and makes commitments for the coming period. “We want to make sure we’re accountable, so we meet weekly and ensure that we’re making progress and refining or improving our goals depending on what’s going on,” he said.

Consider The Zero-Balance Audit

Julien finds that a tool that helps keep the team on track is a zero-balance audit. This is used primarily to measure the net collection percentage, which includes a review of every account that went to “zero balance” in the prior month. It involves a complete review of accounts that are now at zero balance, with a payer-specific comparison of collections for each procedure versus contracted rates.

“This helps us get closer to our goal of maximizing legitimate revenue,” he said. “This report confirms that things aren’t just being written off.” Other problems uncovered during this step could involve prior authorizations that are being missed. “We can see where our net collections are and where we stand for each payer and procedure,” he noted.

Using this variety of tools, Julien said, the practices he oversees saw positive results and an improvement in collections rate. “We definitely think we’ve got a win here as far as our improved yield and our goal of improving revenue,” he said.