Healthcare is a very complex field. After attending college and Medical School, physicians invest years of time and effort to learn the focus of their specialty. Pediatricians spend three (3) years in Residency after Medical School. Pediatric residency includes rotations in NICU, PICU, ER, Cardiology, Pulmonary, office practice as well as other areas related to Pediatrics. This is much different than a Surgery, Ortho or Radiology Residencies. Similar to the Medical training in Pediatrics, the coding in Pediatrics is differs from other specialties. There are routine updates to the CPT and Diagnosis codes as well as the scrubber logic/systems at insurance companies. This requires continuous learning and improvement by the entire billing team and providers.
The revenue cycle is comprised of the front end and back end. Traditionally, a practice labels the back end of the revenue cycle as the “billing team”. This is only half correct. The front desk and providers (front end of the revenue cycle) are a critical component of the revenue cycle to insure that the proper procedures/codes are captured at the time of the visit as well as to appropriately check in the patient. A well designed system can optimized the revenue cycle for Pediatrics by attaching code automatically (e.g. when a vaccine is added, the administration codes added automatically). The back-end billing team needs to submit & resubmit (as needed) the claim to the insurance companies, print patient statements and follow-up on the claim. The back end billing team should also have communication with the front desk and providers related to appropriate update/changes in billing practices and/or a certain claim.
There are many variables in the revenue cycle including: patients/families with various types of insurance (HMO, PPO, H.S.A.) as well as numerous insurance companies each with their own payment structure and systems. The front desk team needs to be trained on how to intake insurances for verification. Additionally, the front desk team needs to be monitored and provided feedback on their work performance. The Pediatricians and/or providers also need some initial training on coding and monitoring to provide feedback on what they are doing well as well as what they can do to improve. I have seen some providers be able to identify all appropriate billing opportunities while others have a small range of variability in their coding.
Think for a minute of the range of codes in a Pediatric visit: a simple sick visit with one diagnosis and one CPT code (e.g. 463 – DX code, 99213 – CPT Code) to a complex well/sick visit that includes multiple vaccines (e.g. greater than the eight diagnosis codes and more than 6 CPT codes). If a provider averages 80 patient visits a week for fifty weeks a year, the provider see approximately 4000 patient visits a year. This Pediatric provider might have 25,000 to 35,000 CPT/DX codes attached to these visits. A well designed system as well as trained providers, front desk and back-end billing team utilizing a system designed for Pediatrics built on today’s technology should optimize the revenue cycle for the practice. The system should automatically attached procedure CPT codes when a procedure is selected. Also, when a vaccine is given, the system should automatically attached administration codes. Well check coding is very similar for each visit with the variables being the procedures, vaccines and/or if the patient is also sick and should have sick codes. The practice should have a clearly written policy on how they manage the fall flu injections. This policy needs to be shared with the front desk and back-end billing teams.
The American Academy of Pediatrics has a good selection of training courses for providers and back end billing team members. Providers should routinely take courses and/or obtain updates so they can appropriate select the ‘right’ code for the visit. Pediatricians and pediatric providers have much to manage in their practice. For even a highly skilled Pediatrician, managing all the details associated with a practice is very time consuming and challenging. Providers that do not have a strong understanding or interest in the revenue cycle of a practice might have unrealistic expectations on managing the details of the revenue cycle (e.g. variability of payment from different insurance companies, % of patients that pay). Organizations, such as the Medical Group Management Association, have tools and benchmarks for practices. These benchmarks include % of revenue collected to the contract amount as well as the average amount of accounts receivable waiting to be paid. A well design system should be able to provide reports to evaluate both the ‘big picture’ as well as to drill down on each detail. As the front end and back end billing team move to a steady state, a partner should invest a few hours a month to run the reports to see the status of the practice performance. If the practice is performing above the performance benchmarks, congratulate yourself and your team. If the practice is performing below the performance benchmarks, identify the issue: is it a revenue capture by the providers? Speed of being paid? Amount of $ in Accounts Receivable? Is it patient collections?
There are numerous articles written on why practices should outsource their billing operation (the attached link is an example http://www.softwareadvice.com/articles/medical/medical-best-practices-advice/when-should-you-outsource-your-medical-billing-1032610/ ). The providers still need to optimize their check-in procedures as well as select the procedures when outsourcing their billing. Many outsource billing organizations have limited transparency. The practice should be able to audit the back-end billing team ‘real time’ as needed. The back-end billing operation should have a written audit process for which billers audit each account. The back-end billing team should also have coverage when the primary biller or billers are on vacation or sick leave. The providers need to have a resource in the back end billing team to ask or send questions/clarifications.
Although healthcare is a complex field, a well designed system and processes along with proper training can simplify the work for a practice, optimize the revenue cycle, and minimize the staffing cost to a practice.
