Overcoming Challenges in Medical Billing: The Appeals Process

July 27th, 2010 by Joann Doan

Gavel and StethoscopeAppeals are a normal part of the medical billing process, but that doesn’t make them less frustrating or time-consuming. There are steps you can take, however, to make the appeals process much smoother and more profitable for your practice.

First, take a bird’s eye view and review your most commonly denied claims, prioritizing both for volume and dollar value. You want to use this information to focus your attention where it’s going to benefit your practice the most. You should also know the cost of appealing claims—that will help you prioritize those claims that will net the most for your practice and will also help everyone in your office understand the importance of eliminating denials before they occur whenever possible.

Be sure your appeals process also addresses priority by payer deadlines:

1. Prioritize by shortest deadlines, then by largest amount due.
2. Draft and distribute a list of payer deadlines to insure your appeals are filed in a timely manner.

Next, develop a standard process for addressing the most common denials that represent the most revenue for your practice:

1. Develop a letter template that can be quickly generated and sent for each appeal.
2. Consider designating specific staff members to handle particular denials so that they can develop expertise in that area and learn to expedite the appeals. Make sure your staff is cross-trained so that denials aren’t delayed by a staff member’s absence.

Each appeal letter should include key information:

1. Patient name and demographics, insurance account numbers and employer information
2. Date of service
3. The CPT and ICD-9 codes
4. A short, clear explanation of what you are appealing (denial, underpayment) and why (explain medical necessity, authorization received, etc.)

Use your template or a checklist to ensure you include all of this key information–it’s easy to leave an item off in the rush of the business day. Make sure you scan supporting materials so that you can easily find and attach them to the appeal letter.

Of course, one of the key steps in the process is to evaluate your most common denials so that you can eliminate them before they occur, as mentioned above. You will want to evaluate your report of most commonly denied claims to make sure you are addressing root causes and avoid the need to appeal to begin with.

If you are using Kareo, you can generate denial management reports that group your denials and rejections by reason and dollar amount, trended over time. This helps you identify frequently recurring denials and rejections that can be addressed through process changes in your practice. For example, if you’re routinely receiving denials because the patient is ineligible for insurance coverage, then you may want to begin verifying each patient’s insurance eligibility prior to scheduling appointments.

But regardless of how you do it, spend time organizing your claims appeal efforts to insure you:

1. Eliminate root causes of denials wherever possible.
2. Prioritize your appeals to insure you are pursuing the highest dollar return.
3. Standardize your process so that it is as efficient as possible.

These steps will enable you to improve the productivity and profitability of your appeal processes, your medical billing, and ultimately your practice or billing service.

Do you have suggestions for ways to improve the appeals process or improvements to the ideas in this article? Please share your comments with your colleagues by using the Comments link below. We appreciate your input!

Read More | 1 Comment | Filed in Features, General

Don’t be Distracted by the Shiny Objects of EMR and HITECH Incentives

July 20th, 2010 by Joann Doan

Hypnosis: Don't Be DistractedOne of the blogs that I like to read, The Healthcare IT Guy, posted some good thoughts last week about the final MU rules for EMR and what physicians should do next. I liked his advice, which included:

  • Don’t be in a hurry to make an EMR/EHR decision because of incentive payments; even if you start in 2012 you’ll be eligible for full payments from Medicare ($44k over 5 years) and you can start as late as 2016 to get full payments from Medicaid ($63k+ over 6 years). If you’re making EHR/EMR decisions based on other business benefits and not incentive payments then you should continue that research and decision-making process.
  • Do be in a hurry to use technology that helps with office automation first (like document management, patient relationship management, etc.). General office automation technology won’t qualify you for incentive payments but it will help reduce your costs and you’ll run your business better. If you use the proper technology you save more in one year than you’ll get back from incentive payments in 5 years.

His second point is especially important, from my point of view. Too often, we are entranced by the latest idea to generate revenue or build business, and we’re distracted from the tried and true techniques for maximizing revenue we’ve already brought in the door.

A doctor I know has a good expression for it: “Stepping over dollars to pick up pennies.”

A good example of this is that $44,000 incentive, which every EMR company is waving in your face. The $44,000 is a tantalizing figure, no doubt about it. But did you realize that you could earn a great deal more than that through improved medical billing and collections?

Let’s start with the fact that it’s not uncommon for medical practices to report a gross collection rate of 60 percent or less, according to The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid. That means for every $1 of services billed, the physician receives only 60 cents.

Then, consider the impact of denials: Gross charges denied by payers have grown over the last decade to 14-18% of all charges. That translates to $118,800 of lost revenue for the typical primary care physician. Some other food for thought:

  • Denied, rejected, resubmitted and underpaid claims can cost you as much as $100,000 per month according to the AMA.
  • Your practice could be losing more than $75,000 per year in denied claims that are never resubmitted, based on multiple studies confirming that many practices do not resubmit up to 50% of their denied claims.
  • Underpayment of approved claims has historically been as much as 35% lower than the contract amount.

What all of this means is that you could be bringing more money to your bottom line—without adding a single new patient or working another hour longer—or chasing the EMR incentive. Naturally, we believe the best way to do this is by fully utilizing the best possible medical billing software and insurance claims processing best practices to insure that your claims are clean, your appeals submitted and collections are as high as possible. And if you do those things, you will not only put more in your pocket than you will with the HITECH incentives, but you will have a better-run practice overall, as The Healthcare IT Guy mentioned.

I’m not saying you should ignore EMRs and other technology. You should certainly seriously consider an EMR for your practice, if it makes sense for your practice. Kareo is not opposed to EMRs, and in fact recently announced an integration with Practice Fusion, the free, ad-supported EMR, to offer our customers that option.

We just don’t want you to be distracted by that shiny object and miss out on money you’ve already earned—and deserve.

Because we believe you deserve the dollars…as well as the pennies.

Read More | 1 Comment | Filed in General

Announcing Our First Medical Billing Tip of the Month Winner

July 13th, 2010 by Joann Doan

We’re pleased to announce that the winner of our first “Medical Billing Tip of the Month” contest and recipient of a $250 American Express gift card is AJ Riviezzo, MBA, who is CEO of American Physician Financial Solutions, LLC.

We received many excellent tips on how to streamline the medical billing process and better use medical billing software, and we thank everyone for their submissions. Below you will find the winning tip, as selected by our judging committee, and the two runners up.

Billing Tip of the Month Winner:

Pro-Active Notes Process Decreases Time to Payment on Elective Procedures

Many elective procedures require not only a preauthorization, but are frequently subject to review post- procedure. This review typically consists of sending documentation to the payer for their review. Examples of said documentation may include any diagnostic laboratory or radiology studies, the operative reports, and perhaps a Letter of Medical Necessity.

Waiting until the claim has processed and been denied with a request for notes can significantly delay payment. If these types of procedures are a large part of your practice, your accounts receivables have just increased by quite a number of days.

Our recommendation is to note which payers are typically requesting the aforementioned notes. Once that it is identified, we then begin to send notes in a proactive fashion. We submit the claim electronically through Kareo medical billing software. One week after the claim has been received by the payer, we send the notes (either fax or snail mail depending upon the payer) to the payer. When we receive the EOB stating notes are required/zero pay, we call the payer and indicate that notes should already be on file and ‘force’ them to reopen the claim right then.

This process has helped decrease the time to payment on these elective procedures.

AJ Riviezzo, MBA
CEO, American Physician Financial Solutions, LLC
719.233.0099

Quick Method for Checking Rejections, Denials & “No Response” Claims

1. In Kareo, go to “Track Claims” status.

2. Change drop down from “All Claims” to “Rejections” and hit “Find Now.” This will pull all patients that had some kind of error in sending out the claims.

3. Double click on the patient name and it will open the claim so you can review the clearinghouse response. Scroll down to the last responses and read through them to see the reason it was rejected. This doesn’t always show up on the clearinghouse reports. Once you’ve identified the issues, you can deal with each rejection appropriately.

4. After reviewing these claims, then you can change the drop down to “Denials” and do the same thing again.

5. Change the drop down to “No Response” and go through these claims. (Some of these have not been denied but should be reviewed as the system has marked them as an error.)

This will help cut through the A/R faster and keep current claims moving through A/R.

Kathleen Cancilla
AllDocuments, Inc.
(650) 556-1000

Reducing A/R By Checking for Co-Pays in Advance

One of the best ways to improve collections is to run your patient list for that day or a couple days ahead and check for co-pays for insurance. Also check the Kareo system for outstanding balances. At the office, we have the patient face to face and need to make them aware of the balances due for services rendered. I have found this to be a very good way to keep our A/R down and the doctor happy. Most patients want to pay so they do not get behind.

I have been doing this for the past 20 years that I have been in the medical setting. It seems to be just good business.

Barbara Jones

Submit Your Entry for the August Medical Billing Tip of the Month Contest

If you would like the opportunity to win $250 and get your company name in front of thousands of potential customers, enter our Billing Tip of the Month contest for August. Just submit your best billing tip by July 26 via email to Marketing@Kareo.com. We’ll announce the winner by August 11 and will post the best tips on our website and in our monthly e-newsletter, giving you and your company credit. (Please be sure to list your company name in your entry!).

Good luck!

Read More | No Comments | Filed in Company, General

New Free Medical Billing and Practice Profitability Resources

July 7th, 2010 by Joann Doan

Our goal at Kareo is not just to provide you with easy, affordable medical billing software; we want to help you be as successful as possible, and that means providing useful information on practice management, specifically improving practice profitability; techniques for making the most of medical coding online to improve medical billing productivity; and methods for insuring speedy processing of your electronic claims.

To that end, Kareo is introducing two new resources for you:

First, we are pleased to announce the upcoming launch of our new free e-newsletter in August. This quick-read monthly newsletter will provide short articles by experts in the field, tips for improving productivity, streamlining your billing and collections processes, and getting the most from your medical billing software. As an example, the first issue will include:

•  A Dozen Steps to Successfully Appeal Denied Claims
    By Elizabeth W. Woodcock, MBA, FACMPE, CPC
    Co-Author, The Physician Billing Process: Avoiding Potholes in the Road to Getting Paid
•  Tips for Improving Productivity in Your Billing Processes
    By Michelle Rimmer, CHI, CPMB
    President, Professional Medical Billers Association, LLC
•  Case Study of a Successful Physician Practice or Billing Service
•  Billing and Coding News
•  Billing/Coding Tips & Tricks

If you have suggestions for upcoming articles, we want to hear from you. Please email your ideas and requests to Marketing@Kareo.com.

We are also soliciting articles from medical billing practitioners and practice profitability experts. If you are interested in contributing an article for the newsletter, please contact us at Marketing@Kareo.com. This newsletter will provide excellent exposure for medical billing services and consultants, so if you are interested in sharing your expertise with a large, interested group of potential customers, please contact us.

Second, you will find new resources on our video training page, where we’ve added several new training videos on:

Managing Other Codes
Setting Up Other Lists
Setting Up Departments
Using the Patient Account Ledger
• And much more

Check back on our video training page frequently, as we are recording new training videos almost on a daily basis. If there’s a subject you’d like covered in a training video, again, please let us know at Marketing@Kareo.com.

We hope these resources will help you achieve new levels of success, and we will continue improving all of our offerings toward that goal.

Read More | No Comments | Filed in Company

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