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Any strong medical billing process and medical billing company must compare insurance payments to your contractual allowables and aggressively pursue underpayments. If this is not happening then most likely 5 to 10% of your practice’s revenue is being lost.

Medical billing services have a number of basic steps they should incorporate into their billing process. These steps should include using a claims scrubber, use of no-response calls, posting zero pays, pursuing underpayments, and using likelihood of payment scores for patient collections.

Pursuing underpayments is the focus of today’s article. This pursuit begins first and foremost with comparing the payment information from EOBs to the allowables outlined in the practice’s payer contracts. This comparison must be done in an automated manner and cannot rely upon payment posters catching the underpayments on their own.

The reason that comparison to allowables must be automated is because of the clever and systematic manner in which payers typically underpay claims. These underpayment patterns can be difficult to spot, but one of the advantages a Medical Insurance Billing Service has is that it sees payment information and patterns across many clients for many payers. This allows medical claims billing services that regularly and systematically compare payments to contractual allowables to spot patterns that a single practice might miss.

A disturbing pattern that can regularly be seen by a medical billing company that is paying attention is one where a payer will select a set of procedures and underpay this set of procedures across a large number of providers (often by the same amount). This will continue for about 30 days and then the payer will resume paying the procedures at the correct amount and begin underpaying a whole new selection of procedures.

Although the amount of the underpayments may be small ($5 to $15), the totals can be quite large: upwards of a 10 percent net reduction in the payments the payer sends the practice. Despite the magnitude of the total, the constant hopping from CPT to CPT for underpayments and the relatively small amount of the underpayment on any individual claim makes the loss of revenue hard to spot – let alone pursue.

The pattern outlined above is why it is critical that a strategy for pursuing underpayments is not based upon payment posters picking up on the underpayments. Most payment posters will notice a large underpayment, but it is too much to expect them to spot a $5 underpayment.

Identifying and pursuing underpayments can yield big returns for a medical practice (the average practice can increase collections by 7%). Therefore, it is imperative that your billing service is aggressively pursuing these underpayments on your behalf.

Identifying the underpayments is the first step of the journey. Dogged pursuit of the underpaid amounts is what actually drives up your practice’s revenue. This pursuit needs to go down to even small underpayments because once a payer sees that the small underpayments are being pursued they typically taper off and contractual payments resume at the appropriate level. Much like a small child, the insurance companies are trying to see what the can get away with.

Copyright 2008 by Carl Mays II

According to many polls, by January 31, 2009 the majority of New Year resolutions will have already been abandoned. This does not mean that it should be a day of mourning, but rather it is the time to take stock of what needs to be done to reach the goals that were set at the end of 2008. It is critical to keep in mind two of the corner stones for achieving any goal:

1. View your failures (i.e., I have not flossed in two days) as minor set backs and not as utter failure (i.e., I might as well start saving for dentures); and

2. Focus on a sequence of short term goals that make your larger goal seem more manageable (i.e., instead of “I will weigh 120 pounds by December 31st” set a series of goals such as “I will weigh 152 pounds by the end of February. I will weigh 148 pounds by the end of March.” etc).

So, this is interesting, but how does it apply to medical billing? Well, if you keep these ideas in mind you can use them to achieve lofty improvements in medical billing performance. How? Start with a powerful and straight forward goal: Make sure your claims are clean before you submit them. This will help your medical billing in several ways:

- This goal forces you to concentrate on the most critical elements of medical billing – gathering the proper information and using it to create a clean claim;

- This goal can be easily broken down into smaller goals such as “I will improve my acceptance rate by 2% per month or I will implement a claim scrubber by the end of March;

- Set backs position you for better performance tomorrow. How? You look at the claims that did not go out the door clean and learn what went wrong. Do you have a problem at the front desk with gathering demographics? Do you have a problem with training your data entry people? Do you have one physician that consistently codes incorrectly? Do you have one payer that really dislikes one of your common procedures?

- It lends itself to technology aids. Invest in a scrubber that will help you find coding problems before you submit the claims. Invest in insurance verification tools that will make it easier to have clean demographics. Invest in coding tools that will help improve your data entry performance.

Use the end of January as the time for a more informed New Year’s resolution for your medical practice. Today is the time for you to:

- Understand where you are starting your journey (what portion of your claims are accepted on first submission);

- Decide upon a stretch target (I will increase my clean claim percentage by 15 points this year);

- Create a “goal ladder” where each rung of the ladder represents an incremental, achievable goal on the way toward your ultimate goal. For instance your may set incremental goals of improving your clean claim performance by 1 percent each month; and

- Develop a process for gleaning learning from claims that do not initially clear the clean claim hurdle.

This approach and focus can allow your medical billing efforts to reach new standards of excellence in 2009.

Copyright 2009 by Carl Mays II

Medical billing is a crucial health care service that supports physicians by submitting and collecting the payments from insurance companies and patients. One needs to be an expert to ensure that the bills are collected fully and in a timely fashion. It is quite common for over 20% of a practice’s potential revenue to remain unclaimed because of improper coding and weak collection strategies.

Medical billing outsourcing is an accelerating trend that medical practices and facilities are utilizing to level the playing field between them and the insurance companies. Potential outsourcing options go from individual medical billers working from their home to medical billing services that with thousands of providers.

In thinking through the billing options available, it is crucial to understand that medical billing is complicated and requires deep expertise and broad experience. When a specialty is involved, such as surgical billing, the requirements for success become even harder to achieve. Success requires that the medical billing company have a team that is well versed with the complex rules utilized by insurance companies to adjudicate surgical medical claims.

As the cost of providing surgery related healthcare services continues to rise, medical institutions and surgical practices cannot afford to leave revenue uncollected by billing companies or freelancers that are not knowledgeable in surgical billing. It is also important to keep in mind some companies may promote themselves as large surgery billing service providers but in reality they sub-contract the surgery billing to freelancers who work from home. Hiring such companies will lead to lost revenue because of the lack of proper process, controls, and training.

Deep familiarity and comfort with surgical procedures and terminology does not come from serving one or two surgeons. Surgical billing success requires both broad and deep expertise in order to collect all of the money owed the surgeon and successful appeal claims which have been denied or answer questions the payers may have about a claim.

A company that does not encompass a wide range of surgery billing experience will find it difficult to track underpayments since multiple procedure rules and surgical procedures have significantly more complicated contractual adjustments than a typical family doctor or internist’s claims. In addition, the billing software and system design of a generalist billing company will often be insufficient for the more complicated requirements of reporting and insurance follow-up required in billing for surgeons.

These billing complications extend to the patient collections arena as well. The patient collection process for specialists like surgeons is more complicated because of the large patient balances often owed, the complexity of the procedures/EOBs that must be explained to patients that do not understand their bills and the older population surgeons often serve. A medical billing service with expertise in billing for surgeons knows how to deal with these situations. Billing services without such experience will increase the risk of both lower patient collections and upset patients confused about their bill.

The safest way for a surgeon to navigate the medical billing land mines outlined in this article I to travel the medical billing battlefield with a surgical billing service that has deep and proven expertise in traversing the surgery billing hazards. Family doctors should not be performing surgery and generalist medical billing companies should not be providing medical billing services to surgeons.

Copyright 2008 by Carl Mays II

Medical billing is a critical service that supports healthcare providers by submitting claims and collecting payments from insurance companies and patients. Medical billing specialists need to be experts to guarantee that the bills are in full and in a speedy manner. It is quite common for over 20% of a practice’s collectable revenue to remain unclaimed because of improper coding and ineffective collection tactics.

Outsourcing medical billing is growing in popularity as a method for addressing this remarkable loss of practice income. The range of outsourcing options runs from exceedingly large organizations to individual freelancers working from home to provide medical billing services.

Medical billing is a highly complex area and it requires experience-based knowledge and expertise to contend with insurance companies. When it comes to cardio billing, the situation gets even more complex. Such complexity can be handled only by a company that is staffed with well trained cardiac billing professionals. The medical billing specialist must be familiar with the specific codes and rules that make up the world of cardiology billing.

As the cost of providing cardiovascular related healthcare services continues to rise, medical institutions and cardiology practices cannot afford to leave revenue uncollected by billing companies or freelancers that are not knowledgeable in cardiovascular billing. It is also important to keep in mind some companies may promote themselves as large cardiology billing service providers but in reality they sub-contract the cardiac billing to freelancers who work from home. Hiring such companies will lead to lost revenue because of the lack of proper process, controls, and training.

Deep familiarity and comfort with cardiology procedures and terminology does not come from serving one or two cardiologists. Cardiac billing success requires both broad and deep expertise in order to collect all of the money owed the cardiologist and successfully appeal claims which have been denied or answer questions the payers may have about a claim.

A company that does not encompass a wide range of cardiovascular billing experience will find it difficult to track underpayments since multiple procedure rules and cardiovascular procedures have significantly more complicated contractual adjustments than a typical family doctor or internist’s claims. In addition, the billing software and system design of a generalist billing company will often be insufficient for the more complicated requirements of reporting and insurance follow-up required in billing for cardiovascular practices.

These billing complications extend to the patient collections arena as well. The patient collection process for specialists like cardiologists is more complicated because of the large patient balances often owed, the complexity of the procedures/EOBs that must be explained to patients that do not understand their bills and the older population cardiologists typically serve. A medical billing service with expertise in billing for cardiology knows how to deal with these situations. Billing services without such experience will increase the risk of both lower patient collections and upset patients confused about their bill.

To avoid all these billing related pitfalls cardiologists need to utilize specialized cardiovascular billing services. It is not advisable for an internist to perform heart surgery, similarly someone without training in surgical coding and surgical billing is not qualified to offer reliable billing services for cardiologists.

Copyright 2008 by Carl Mays II

Most people’s New Year resolutions have been abandoned by the end of January. If you find your self in this group then take heart. You can still snatch victory from the jaws of defeat. To do so, you must understand two basic principals of achieving your ambitions:

1. Treat your set backs as temporary failures and not total defeat (i.e., just because you broke down and smoked a cigarette does not mean you should just say I failed on my goal to quit smoking); and

2. Focus on a sequence of short term goals that make your larger goal seem more manageable (i.e., instead of “I will weigh 120 pounds by December 31st” set a series of goals such as “I will weigh 152 pounds by the end of February. I will weigh 148 pounds by the end of March.” etc).

Although these concepts may seem simple, they are quite powerful – not only in your personal life but in your business as well. These two ideas can be leveraged to dramatically improve your medial billing this year. A great way to start this journey is with the goal of having 95% of your claims accepted on the first submission. This goal will have an extraordinary impact on your medial billing performance:

- You can only achieve it by having a laser focus on the front end elements of medical billing. This is where the medical billing “game” is won or lost;

- This goal can be easily broken down into smaller goals such as “I will improve my acceptance rate by 2% per month or I will implement a claim scrubber by the end of March;

- This goal has many ways in which failure provides powerful learning opportunities. You can set aside time to analyze rejected claims to determine the source of the rejection and then focus on eliminating the problem area.

- There are many tools available to help you achieve this goal. They include claims scrubbers, coding tools, training seminars and insurance verification tools.

Use the end of January as the time for a more informed New Year’s resolution for your medical practice. Today is the time for you to:

- Determine where you stand today (what percentage of your claims get paid on the first submission);

- Write down a powerful and meaningful performance improvement goal (my practice will have over 95% of its claims accepted on the initial transmission);

- Break them down into bite size pieces (I will improve clean claim submissions by 2% each month), and

- Develop a process for gleaning learning from claims that do not initially clear the clean claim hurdle.

Implement these steps and you can achieve significantly better medical billing results in 2009 than you realized in previous years.

Copyright 2009 by Carl Mays II