Surgical Billing | Blog

Surgery Billing and Revenue Cycle Denial Management

Surgical Billing Partners — Tue, 07 Oct 2008 17:55:00 GMT

Revenue Cycle Denial Management has become a universal and often abused term in medical billing. Some use the term to describe a means of addressing claims denied for medical necessity. Others use the term to describe how some information is tracked for a specific payer, set of procedures or a place of service. Still others try to use it to describe what they do daily in the physician’s office.

If you were to ask your billing department or a current billing company (1) what is their Revenue Cycle Denial Management strategy; (2) what process do they use to methodically measure it and (3) what are the quantifiable results of it, you would most likely get a lot of blank stares.

Few billing departments appreciate the value a good Revenue Cycle Denial Management system can bring to a surgery practice. A robust Revenue Cycle Denial Management system provides methodical management data for the billing process; the data are then used to (a) increase and (b) accelerate cash flow. The system accomplishes this needed service by tracking, quantifying, and reporting on every claim billed for which any payer denied the service. The reporting should be comprehensive, tracking all denials (not just selected denials). If used properly, the system can reduce first-time claim denials by over 50 percent. In our experience we’ve come across many practices with no way of monitoring if the payer is denying their claims at excessive or unwarranted rates, or even for what reason. These practices are probably losing 10-20 percent of their total revenue.

For an average surgery group, that could be as much as $1.0 million dollars annually. What is typically missing from troubled billing operations is the lack of the management-reporting expertise needed to extract the data in a concise and meaningful way coupled with a lack of methodical, measured billing process needed to correct mistakes.

Surgery Billing Partners' comprehensive Revenue Cycle Denial Management system has two main purposes. First, to provide feedback on why and how many claims are not being paid on the first submission to the respective payers. The second is to fix these issues. Surgery Billing Partners' Revenue Cycle Denial Management software databases have been designed to track, quantify, and report on all denials for all payers. The standard output tracks, by payer, the number of claims denied and the reason for the denials. This is coupled with our Dashboard reporting for a quick visual management. With these unique reports our team can easily identify which payers are inappropriately denying claims; we can also compare these payers to their peers for proper trending and follow-up. The unique output for each practice allows us to refine the payer specific rules and build our own rules to prevent future payer denials. Payers that are chronic violators are pursued to resolve how and when they intend to process and pay outstanding claims. If the issues persist, there may be grounds to charge penalties stipulated by the Clean Claim Law (to the extent it exists in the state). Only by quantifying and analyzing the problem can you discover how to improve on the process. A real Revenue Cycle Denial Management system gives you a way to optimize and accelerate cash flow. Surgery Billing Partners' system has a proven track record of improving revenues between 5-20 percent.

For more information visit Surgery Billing Partners' website.

Surgery Billing Responds to Clean Claims

Surgical Billing Partners — Wed, 17 Sep 2008 22:05:00 GMT

One of the most important things in billing is to create and follow a very structured plan that can be measured each step of the way. Remember, if it cannot be measured and monitored it cannot be improved!

Clean claim submission can reduce average days in AR to less than 45 days

The leading surgery billing operations utilize scrubbers that ensure your claims are clean before they are submitted to payers. These scrubs accelerate the speed of collections by avoiding denials and delays. They also increase collections by minimizing the volume of “re-work” and allowing billing staff to focus their efforts on pursuing true collections improvement opportunities and not simply resubmitting claims that should have been paid the first time. As a result of these scrubbers, over 90% of claims submitted are paid upon first submission. These “scrubbers” include:

Basic mechanical scrubber that assures that all claim fields have been properly filled with formatted data (social security number with 9 digits, date of birth etc), the NPI is in a proper field, there is a referring physician if needed, etc.
Scrubber that checks coding, bundling, and procedure information versus local Medicare and CCI rules. This scrub assures better coding, identifies overlooked procedures or codes.

The truly great surgical billing specialists can rely on surgical specific know-how and business intelligence created over time through work with many surgeons in the given payer relevant geographic area.

Dynamic Proprietary Rule scrubber that checks for optimal coding and documentation versus the particular payer or plan’s rules. This scrub assures that each claim is optimized for clean submission. When the payer or plan’s rules change or when the billing office detects a systemic issue they can update the scrubber to filter and fix problems before claims go out. These specialized surgical scrubbers can make a significant collections difference.

At Surgical Billing Partners we have found that these actions can decrease the medical practice's collections cycle by up to 40-50 days. This is why you need to insure this critical step is being completed no matter who is doing your Medical Billing.

If you would like to learn more please visit Surgical Billing Partners' website.

Surgical Billing Companies Can Use Clean Claim Laws to Increase and Speed Up Collections

Surgical Billing Partners — Thu, 11 Sep 2008 00:12:00 GMT

Clean Claim Laws are currently in place in every state. The assistance provided by the laws ranges from states like dramatically South Dakota which has no economic penalty to Texas where the payer sometimes is required to pay billed charges. The fundamental concept is that insurance companies must respond to a clean claim within a given period (typically 30 days for electronic claims). Systematic utilization of these laws will allow a surgical billing service or practice to significantly accelerate and increase collections. In order to take advantage of the clean claim law one must have a monitoring system built into your medical billing process that identifies:

Which payers must abide by the clean a claim law (the laws do not apply to all payers),
The date the clean claim "clock" begins (i.e., the date a claim is submitted),
Events that stop the clean claim clock (e.g., an information request from the payer),
Events that restart the clean claim clock (e.g., your office replies to a payer's information request), and
When you received a payment or denial.

Designing and implementing the monitoring system can be difficult, but it can have an significant impact on how quickly your claims are paid cleanly. Surgical Billing Partners has actually received calls from payers assuring us they will process our clients' claims quickly and asking us to please stop submitting complaints.

An easy way to get started with using the clean claim law is to pick a specific payer that you believe consistently delays claims beyond 30 days. Find a small number of large that have gone past 30 days and then conduct a trial run with those claims. This will allow you to learn the fundamentals of how to submit and monitor complaints and see the impact of your the complaints.

Surgical Billing Services Can Help With Underpayments

Surgical Billing Partners — Thu, 11 Sep 2008 00:08:00 GMT

If you make the decision to outsource medical billing, then make sure your medical billing company compares your payments to your allowables. It goes without saying, that if you do billing in-house the comparison still should be done. One of the advantages a specialized Surgical Billing Service has is that it sees payment information and patterns across many surgeons for many payers. This allows surgical billing services that regularly and systematically compare payments to contractual allowables to spot patterns that a single practice might miss. One that is seen at Surgical Billing Partners on a regular basis is the systematic underpayment of claims by payers. As we look across multiple surgeons we will see the exact same CPTs being underpaid by the same amount by the same payer in a given month across all of our clients. The following month we will see the same payer switch to underpaying a different set of CPTs. These under payments are not huge (5 to 10 percent) but they add up quickly to big dollars for a medical practice. The combination of switching the codes being underpaid from month-to-month and keeping the underpayment amount "under the radar" can make this difficult for an individual practice to spot. It is also difficult for a generalized medical billing service to spot if they are not comparing your payments to your contracted rates. At Surgical Billing Partners we have found that this single action (comparison of payments to allowables) can increase a medical practice's collections by 5 to 10 percent. This is why you need to insure this critical step is being completed no matter who is doing your Medical Billing.

If you would like to learn more please visit Surgical Billing Partners' website.

Copyright 2008 by Surgical Billing Partners

Every Surgeon Deserves a Specialized Surgical Biller

Surgical Billing Partners — Wed, 10 Sep 2008 23:57:00 GMT

Medical billers and medical billing services are the financial life blood of a practice. Practices that do not have the right medical billing expertise in their corner can easily lose more than 20 percent of their practice's potential revenue.

As physicians are considering the use of medical billing servers to stop the hemorrhaging of cash from their practices, they are faced with a broad range of options. On the small end of the spectrum are individuals working from their homes. On the opposite end of the spectrum are companies that employ hundreds of medical billers and have thousands of clients.

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

The choice of an experience billing provider has become all the more important for surgeons as they watch their cost rocket upwards. With their margins shrinking they must be confident that their surgical billing service is collecting every dollar the surgeon is owed. Selecting the proper medical billing service is made all the more difficult by the fact that many companies claiming to be experts in billing for surgeons actually do not do the billing themselves, but outsource the work to other vendors that are based in India or work from their homes.

One of the major drawbacks of hiring a company that does not specialize in surgical billing is their lack of familiarity with the procedures and the terminologies used. Even if the medical billing company serves one or two surgeons, they will lack the depth and breadth of expertise required for successful surgery billing. Moreover if the hired company does not specialize in billing for surgeons, then they will not have the expertise to effectively appeal denied claims or answer questions raised by the insurance companies.

Good surgery billing requires the ability to track underpayments. This is more complicated than typical medical billing because of the rules around multiple-procedures. This complication often exceeds the capabilities of the billing software used by generalist billing companies. This is a critical failing since proper pursuit of underpayments can increase a surgeon's collections by 7 to 10 percent.

The surgery-driven difficulties of medical billing encompass patient billing also. A surgeon's patient balance process is more challenging because most of the balances are quite sizeable. Coupling this with the difficulties of explaining to a patient their complicated Explanation Of Benefits and the surgical terminology on their bills drives the need for patient collection specialists that have a strong expertise in surgical billing. If patient are not handles with care surgeons will see their patient collections fall and their patient complains rise - not a good combination.

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. Yopu can learn more at Surgical Billing Partners' website.