Each encounter at a Physician’s office generates numerous Diagnosis and CPT codes. A practice needs to appropriate manage their billing and collections for the practice to be effective and efficient. If a physician has 20-30 patient visits a day, the physician might generate 100-200 CPT codes (or more) each day. Each of these CPT codes needs the appropriate DX codes to optimize payment with each insurance company. Even with the ‘right’ diagnosis codes, Insurance companies change their ‘scrubbers’ and ‘rules’ to accepting claims. For instance, one of the regional carriers changed their scrubbers in Mid March 2010 to deny multiple adm codes 90466 unless the code utilized “Units” on the first 90466. The biller needs to follow-up on the claim, resubmit, if denied, investigate the reason further. In the 90466 example, we learned that neither the local insurance representative or our clearing house group were aware of the change (the carriers do not inform billing teams of the changes in their practices and how to be appropriately paid).
How does your billing team monitor this issue? Do they take the time and extra effort to resubmit the claims? Are there other billers that do not have day to day responsibility for the account that perform an audit 1x per month? What are some benchmarks to monitor how well the practice is doing with the billing and collections?
On the last question, there are standards/guidelines established by the Medical Group Management Association (MGMA). The benchmarks in MGMA are fairly non-biased and provide data for a practice administrator or physician partner to monitor the billing performance. Three benchmarks include % of collections to contract amount, # of Accounts Receivable (AR) days, distribution of sick-code office visits, and % of total revenue spent on billing and collections. The ideal is to move the practice to be collecting above the MGMA benchmark goal, maintain the number of AR days to less than 35, a ‘reasonable’ distribution of visit types, as well as a cost of billing that is within the national rate for the specialty. If your practice is meeting/exceeding all these benchmarks – great job…congratulate your billing team and look for further areas to optimize the revenue cycle. If your practice is below is more than one of these areas, drill down and identify what is the ‘root’ problem and work each week to improve.