Pulmonology Coding Alert

Follow these 4 tips for an up-to-date AR.

In order to receive your deserved pay, you need to do a lot of background work. This includes staying on top of continuous coding updates, working on your EHRs, training your staff to stay vigilant of new compliance and documentation requirements, adhering to proper SOPs, and so on. However, even this may not suffice, and many a time you end up facing problems stemming from the how your claims are getting processed.

You need to supplement all your hard work with the following expert tips on how to intelligently monitor your claims, thus leaving no stone unturned to ensure you’re collecting all the pay you deserve.

Verify That You’re Getting Your Deserved Amounts

In an ideal scenario, when you contract with a payer, you would automatically expect to get the stipulated amount for all of your services in the claim. However, in reality, there are a lot of preconditions and clauses, and you can’t simply trust the insurer to send you your money that easily.

Instead, “Practices should review all their managed care contracts, take a sample of some payments from all insurance companies, and match the payments against their respective contracted fee schedules,” advises Vinod Gidwani, founder of Currence Physician Solutions in Skokie, Ill.

If you’re not getting your contracted amounts, you need to contact the payer and correct the problem.

“Maintain information for the contract renewal to use as a renegotiation tool.” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. “There is nothing more that they can do since it is a contractually-defined fee schedule.”

Pre-Check the Patient’s Eligibility

Most major insurers provide web portals that allow you to check a patient’s insurance information. By checking the patient’s eligibility for a service, “discrepancies can be identified ahead of time and can be resolved before a billable service is generated,” says Trent Shelton of Solutions4MD’s, Inc., a North Carolina-based medical billing and consulting firm.

Don’t miss: “The expansion of Medicaid to managed care, as well as the proliferation of Medicare Advantage plans now require prior authorizations for many services rendered,” Gidwani says. Your practice should know when prior authorizations are required and ensure you get these authorizations prior to rendering the service.

Bottom line: You can head off payment issues by checking patient insurance eligibility ahead of providing the service, says Raymond Kelley, vice president of operations with Bristol Healthcare Services, a medical billing and coding company in Cerritos, Calif.

Ensure Timely Patient Communication

Once a patient comes to your office, collect any co-pay and coinsurance, and then educate the patient on his out-of-pocket expenses that may follow. This step is essential to ensuring that if the patient gets a bill down the line, he won’t be surprised since you already explained the potential payments to him.

Furthermore, once you get the insurance payment and remittance advice for a service, send the patient a bill for any applicable balance right away. A delayed response might confuse the patient, who may not remember the exact nature of the charges.

Note: “If patients are having a procedure done, it is always best to identify any financial responsibility for the patients prior to scheduling the procedure,” asserts Pohlig. “Patients often do not understand that they may have to pay the entire procedure amount when they have a high deductible insurance plan. They become overwhelmed when they get the bill, and often state that although they knew they have a high deductible, but they weren’t prepared to pay that deductible all at once. Scheduling procedures in different locations (when possible) can minimize the patient responsibility as well. Outpatient hospitals yield a higher cost than physician offices.”

Monitor and Manage Claims Denials

Another way to ensure that money keeps flowing into your practice is to catch denials before they pile up. “Make sure that the percentage of claims denied on first submission is five percent or less,” Gidwani notes. This will help you save on the cost of following up on denied claims – which can increase your billing costs and negatively impact your bottom line.

Do this: You may think of setting up a schedule when you’ll run reports to identify unpaid claims in the system. Utilize both activity reports and claim date reports to ensure all claims are worked. You can even configure the reports to run from the oldest date of service to the newest, or you can group them by payer to see where you’re recouping the most and the least reimbursement.

“You may also want to group the denials by highest dollar amount to ensure that you are using your time to recover the most money,” suggests Pohlig.

Remove untimely claims: Once you identify claims that are delayed or on appeal, you need to set them aside for the time being, so that you find the time to address those issues directly later rather than just leaving them in the pipeline with the paid claims.

Perform month-end closure audits: Always send payments on time to patient accounts and perform a month-end close out. That way, you are always timely in letting the patient know his balance. The stakes are high, and you can’t afford to fall behind, because then the whole system falls apart.

Final takeaway: “Making sure that you have an effective AR follow-up plan is a crucial component of your revenue cycle,” says Pohlig. “Having a dedicated process will help to maintain your cash flow. Delegate and appoint tasks to each individual, but also ensure that the team can cover for each other when needed.”