Billing and Collections

2012 Pediatric Practice “To-Do List” or Establishing Goals

December 22, 2011 in Billing and Collections by support Team  |  2 Comments

As we head to the end of 2011, it is a good time for administrators of Pediatric Practices to establish goals for the practice. To establish appropriate goals, the practice needs to take some inventory on how they are doing in different areas of Pediatric Practice Management. Some of these areas include:

• Practice Growth: What is the average growth rate in new patients to the practice per month in 2011 vs. 2012? How can the practice increase the growth rate? Does the practice have appropriate staffing to manage the growth rate of the practice? What are the total patient visits in 2011 vs. 2010 and % change? Was there a change in average revenue per patient visit? What marketing channels should the practice invest that provide the best return on investment? Which marketing channels in the past has yielded the best return?

• Patient Satisfaction: Does the practice have a formal or informal feedback system related to patient satisfaction? If the system is informal, it is important to establish a formal patient feedback system that can help the practice identify areas to improve. If the system is already formal, in what areas has the practice increased their patient satisfaction versus last year? What areas has the practice decreased patient satisfaction? Some areas to consider are front desk interaction, Medical Assistant/Nurse Interaction, Physician/Provider interaction, website, tools and treatments. Evaluate the patient satisfaction scores by provider. There can be good feedback to provide a specific provider on how to improve their impact with patients.

• Provider Satisfaction: Which providers are most satisfied with treating patients? What are their drivers to obtain optimal performance? Which providers are least satisfied with treating patients? What are the reasons for their level of satisfaction (e.g. patient interaction, challenging patients, call schedule, disconnect between their expectations of position and actual position)?

• Billing & Revenue Cycle Management Operations: What is the collection rate for the practice? Is this above or below the Medical Group Management Association (MGMA) benchmarks? What systems can the practice implement to further improve the collection rate in 2012? What is the cost of paying the Billing Company or Billing Staff (remember with own staff to include cost of facility space, postage, taxes, management time for billers)? Is this cost above or below the MGMA Benchmarks?

• Update Practice Charges: This is a good time to review all the CPT codes on the super bill and make updates in the billed rate as well as cash rate. Also, include a plan that requires a review of the insurance contracts and reimbursement rates for the top 4-6 carriers. The insurance company, in general, will pay a reimbursement rate that is the lowest of the Billed amount or the contract amount with the insurance company. There are practices that have not updated their billed rate whom send bills to the insurance company that is below their contract rate. A strong billing team will be able to manage this appropriately and proactively. Physician partners should verify this each year by obtaining a list of the CPT codes, the current billed rate for the practice.

• Cost Structure: Review the primary cost items to the practice. How can the practice appropriate reduce overhead expenses while still providing high-quality care? Some areas to review include: leases for facilities, general and Malpractice insurance, telephone charges, supplies, vaccines, general office equipment. Health plans are just beginning to understand that higher overhead does not mean higher quality care. In fact, there is an acticle in the Boston Globe on December 20,2011 titled “Insurer to Reward Patients for Finding Cheaper Care” – Harvard Pilgrim plan seeks to reduce costs.
http://bostonglobe.com/business/2011/12/20/insurer-reward-patients-for-finding-cheaper-care/a6ajBBBu2hpHZ1IyiRPmLP/story.html
The article provides some background on what is occurring in the state of Mass: “Two reports from Attorney General Martha Coakley over the past two years have documented disparities in what hospitals and doctors are paid by insurers for the same services.” If this is just the ‘start’ then there could be a major change in payments which would benefit high quality Pediatric Groups with lower overhead (regardless of size).

Being proactive on the 2012 goals for the Pediatric Practice early in January of 2012 should help the practice optimize the benefits of these results.

Getting Paid Faster By AmeriHealth Administrators PPO

November 17, 2011 in Billing and Collections by Kirsten  |  Comments Off on Getting Paid Faster By AmeriHealth Administrators PPO

AmeriHealth PPO has joined forces with InstaMed in order to offer ERA’s and EFT’s.  This includes getting paid faster, having claim payments directly deposited into your banks account and the ability to view remittances and details through a secure portal.  There is an easy to fill out one page EFT enrollment form and you just need to attach a voided check and fax the information to them.  Yes, it really is that easy!

HIPAA Version 5010 – Is your Pediatric Practice Ready?

October 31, 2011 in Billing and Collections by support Team  |  2 Comments

There is much noise now about the file version called 5010. What is 5010 and what does this mean to my Pediatric Practice? Claims are transmitted in a file format from practice management/billing systems to insurance companies. The current format is known as 4010. Vendors of software need to be able to adhere to these standards to successfully transmit claims to clearing houses/insurance companies (so the practice can receive payments for services). New requirements in the Patient Protection and Affordable Care Act of 2010 should improve the functionality of sending claims via 5010. This file format change impacts insurance companies, practices, clearing houses and software vendors that provide software for Medical Billing. The goal/reason for the change is an effort to reduce the administrative burden on Physician Practices. Some of the projected benefits include:
• Creation of an electronics funds transfer (EFT) transaction standard as well as operating rules. This should help with matching ERAs and EFT transactions (there are many ‘holes’ in the current standard within the industry which makes tracking payments more challenging).
• Implementation of an electronic claim attachment standard and national plan identifier (NPID)
• Requirement for Health and Human Services to solicit input from providers on administrative items including whether the application for enrollment of Health Care Providers by health plans could be completed in an electronic method.
• Adoption of common approaches to administrative transactions by Health Plans.
• Clarification of a transaction standard.
Currently, authors of articles published in Connexion (a monthly magazine published by MGMA), site that there is inconsistent and non-uniform use of more than 1000 claim adjustment reason codes and remittance advice remark codes. ERAs have been sent by Health Plans for which adjustments are documented incorrectly. Many practices have a difficult time matching EFTs to the ERA files. The conversion to 5010 should help with some of these issues. PhysicianXpress is currently ready and certified for 5010 transactions (ahead of the 1/1/12 due date).

The revenue cycle is very complex which needs to be maintained and managed continuously for a practice to receive consistent and optimal revenue streams. Some billing companies have a low fee but they do not manage the revenue cycle (many only upload claims to the clearing house/insurance companies without follow-up on denied or underpaid claims). There is a major difference from uploading claims to managing the revenue cycle. This is why performance to benchmarks (e.g. collection rate to the contract amount) is so important.

What do you need to do as a practice owner related to 5010? If you use a revenue cycle management service by a professional team, very minimal. If your practice manages all the internal processes then there is a check list of 10+ items that need to be completed. These include: reviewing the processes of the practice, verifying that each component in the revenue cycle is 5010 ready (clearing houses/insurance companies/billing software) and validated, identify if the practice will incur extra cost in software, transaction fees and training from the practice management software, identify if time to switch systems for the practice and/or start on an E.H.R. system.

http://www.mgma.com/5010/

The Differences between Teaching Pediatric Medical Billing and Managing the Revenue Cycle for a Pediatric Practice

October 19, 2011 in Billing and Collections by support Team  |  Comments Off on The Differences between Teaching Pediatric Medical Billing and Managing the Revenue Cycle for a Pediatric Practice

While in college and graduate school I wondered why it was rare for a professor to have experience
managing companies.  After accumulating over two decades of experience in healthcare in various roles I have the perspective to understand why this is:  teaching is a different skill set than managing.  Similar to this, there are companies and businesses that fail because they move outside their core skill set.  For example there are many software companies that have no experience in medical billing but have experience selling software.   One of these companies started as an EMR system about 10 years ago.  Although they developed their software using the most current technology at the time, they were providing a general software solution for any specialty.   This company then moved to provide their software and medical billing for 7% of revenue.  This company lasted less than 2 years with this offering.  The leaders of the company probably realized that they were not familiar and did not have the proper resources to manage the revenue cycle (I am sure their customers voiced their concerns).  The revenue cycle is filled with daily management issues and challenges.   I am sure the company leaders realized that the systems, processes and skills needed for providing both software and medical billing services is much different than providing a general software offering.
  
   The Healthcare system in the United States has many disconnects.  When a company only provides the software the disconnects become the management issue of the users (for example, if an insurance
company has a different coding logic than the standard – in this case, they need to identify the issue and then develop a process solution).  We have interviewed billers that were hired to clean up the issues of a publicly traded stock company whom claim to be the model in practice management/revenue cycle management.  I have also learned from other Pediatricians examples of poor collection and revenue cycle management from a number of companies that provide the service in the industry.   

The challenges of managing both software and medical billing services include:
-The company leaders need to provide the proper technology strategic direction.  Are the leaders still holding onto ‘yesterday’s technology’?  Are the leaders familiar and able to develop a team that moves toward the future versus holding on to the dated technology?

-The company needs to have qualified and up to date technology team members…some questions to ask are there staff with computer science and engineering degrees?  Has the company been able to link
directly with Surescripts for both formulary advice and sending/receiving prescriptions?  

-The company needs to be able to benchmark their billing performance and use continuous improvement to optimize the systems/processes as the market changes. Ask the company to provide their billing performance for their pediatric practices versus national averages provided by the Medical Group Management Association (MGMA).  If they are not familiar with MGMA benchmarks and can not provide the mean performance as well as minimal/maximum…..run away from this option!
-The company needs to be able to identify, develop and maintain billing team members whom achieve
performance for the practice.   Ask how often and the sources of training.  Our billing team participates in quarterly training provided by the American Academy of Professional Coders, the American Academy of Pediatrics and/or the Medical Group Management Association (this takes time and keeps us ‘humble’ since the rules are constantly evolving).
-The company needs to have expertise/focus in Pediatrics – we wouldn’t select a pickup truck for street racing so why do pediatric practices select an EMR system designed for geriatrics?  Because of the high cost of developing and marketing software, companies will provide a general system and leverage their sales and marketing channels to optimize the revenue for each segment.  The field of Pediatrics is too small for a company to become a large company if they focus solely in Pediatrics.  I met a few users of ‘general’ Electronic Health Record Systems this weekend at the American Academy of Pediatrics National Meeting in Boston, MA that are spending 2-3 hours a night completing their charts.
-The company needs to manage the ‘right’ type of technology to optimize medical billing and software
EMR/practice management for a practice.  Client server systems are not the optimal solution – this is why the largest player in general medical billing (AthenaHealth) uses cloud computing and start up capital is ‘chasing’ cloud solutions and not client-server solutions (strong Venture firms have the ability to forecast the future and are able to abandon the past/dated technology) .

Our company meets these challenges by leveraging the PhysicianXpress system:  a cloud-based system for Pediatric Offices to manage the Revenue Cycle, their electronic Health Records as well as their practice.  We maintain a qualified billing team that receives quarterly training in Pediatric coding, we continuously benchmark the performance of the practices we manage, as well maintain a qualified technology team.  We are committed to help Pediatric practices increase revenues while decreasing operating costs as well as administrative burden to the practice.   Practices that implement the PhysicianXpress system do not need to spend time or extra money on maintaining a server or a database/data.  When you go to sleep tonight, do you know that your practice is collecting at >99% of the contract amount?

Pediatric Office Revenue Cycle Management/Medical Billing – Today vs. Yesterday

October 12, 2011 in Billing and Collections by support Team  |  1 Comments

I am amazed at the number of Pediatric offices for which the partners use modern technology in their
home life and have a dated revenue cycle for their office.  Their home activities are expenses while the
office revenue cycle provides the revenue stream for their practice and their income.   Because the insurance companies routinely update systems and processes, the average Pediatric office is at a disadvantage to managing the revenue cycle.  Interesting that I have observed a practice owner drive to the nearest cell phone dealer and within an hour walk out with a new phone and abandon the old phone.  This same practice owner is unable to make a change that will increase their compensation.    Many pediatricians have systems in their office that were either designed prior to the 21st and still being sold today or are using a system that the practice purchased before the start of the 21st century.

I have met ‘Sally the biller’ whom has done the billing for years but is years behind on optimal coding
techniques for the office.  Also, we have picked up work from ‘Sally the biller’ for which thousands of
dollars have been missed in charges not resubmitted or reprocessed correctly.  It is expensive and time
consuming for a practice owner to continuously train and challenge their billing team.  Consultants have a solution – hire them to manage the billing team.   This could increase their billable hours – might be better approach to utilize the consultant a few times a year to audit account and measure versus national benchmark (if they are a high skilled consultant, they are probably busy and flexible on the arrangement).  Hiring a practice manager to manage the billing team as well as other functions might or might not be a good idea based on the size of the practice.  These challenges are especially difficult for a 1-3 physician Pediatric group where the extra headcount might only add cost and complexity to the practice and actually reduce the profit margins.

Some of the items to manage for back office revenue cycle management include: insure qualified Pediatric billers are continuously managing the revenue cycle, monthly deep dive into the account to calculate benchmark performances and evaluate aged claims, auditing, training, change of codes, change of claim file standards, change of scrubbers and claim edits, evaluate distribution of sick coding.   The larger practices also require other factors like the evaluation by provider.  Most pediatric practices become more profitable by focusing on increasing patients and revenue versus spending significant amount of time on these management issues.

Why are major corporations outsourcing?  Because the activity is being outsourced is not the core activity
of their business.  Xerox has run an advertisement campaign that they announce Marriott, a hotel, and
Ducati, an Italian motorcycle manufacturer, outsource their back office operations to Xerox so these
companies can focus on serving their customers.  Shouldn’t a pediatric office focus on their patients and
not back office management?  Optimizing profit margin and reducing administrative burden is always on the ‘grid’ for executives in companies.  Business owners of Pediatric Practices either become too busy to think strategically about this approach or might not have the proper advisers.  The links below show these videos:

Xerox – Ducati http://www.youtube.com/watch?v=e6reT9Ux_gI

Xerox – Marriott  http://www.youtube.com/XeroxCorp#p/c/7/wdi43UA2ofE

Xerox – Virgin Airlines  http://www.youtube.com/watch?v=4YFK54c2qYA

It is confusing for a practice owner to know how to identify a company that performs consistently in
Pediatric back office operations/medical billing.  There are many companies not meeting their growth
objectives of their EHR software and/or consulting practice so they might add in Medical
billing as a service.

When evaluating a company/business to manage your revenue cycle some questions to ask include: what is your collection rate, what % of your customers/clients uses your billing service vs. only your EHR.  Since you have been in
business, what % of the time have you been actively managing pediatric billing and the revenue cycle? If
they have been in business for more than 5 years and started medical billing within the last 5 years, their
processes and company systems were not built from the ground up around the revenue cycle
management of clients.  How do you audit my account?  How do I audit your actions?

Transitions from the old model means some changes for the practice:  new systems, processes and potentially a new
billing team.   If done properly, at the end of the rainbow is additional revenue, higher profit margins, reduced work and more free time for the practice owners!