Managing Medical Claims: Avoiding 100K Loss in Revenue.
A specialist physician running a solo practice came to me with a troubling issue: his take-home pay from his private practice had decreased significantly. My first thought was, why didn't he notice something was wrong sooner? Waiting until your proceeds are much lower to realize there's an issue is too late.
Dr. Smith (a pseudonym for confidentiality) lacked a process for monitoring the refiling of claims after they had been denied or returned for further information.
While his initial claims were likely filed on time, many were denied for various reasons: no coverage, wrong payer address, non-covered service, missing preauthorization, and more. This raised several questions:
Had his staff verified eligibility before submitting the claims?
Were the claims sent to an outdated insurance company address?
Did the diagnosis code not match the procedure code?
We all know claims can be rejected for many reasons, but this doesn't mean you can't secure payment for those claims. Upon denial, the claim must be researched and resubmitted promptly. Providers have 12 months from the date of service to request reconsideration, so prior authorizations must be updated before resubmitting a claim.
Key Performance Indicators
In your practice, are you tracking:
The number of claims submitted weekly,
The number of claims approved or denied weekly,
The number of claims resubmitted weekly, and other key performance indicators (KPIs)?
If Dr. Smith had tracked his denials per week and resubmissions, he would have seen that denials far exceeded resubmissions. It's often easier for staff to submit the initial claim than to research and correct a denied claim.
Importance of Management Reporting and Dashboards
This is why management reporting and dashboards are critical to your success. As a physician owner, practice manager, chief operating officer, or billing manager, it's up to you to set up a dashboard of KPIs to monitor your practice's operations. This provides an early warning system for potential issues, rather than waiting to see if there's enough money in your bank account, which is often too late.
Steps to Ensure Timely and Accurate Claim Filing
1) Patient Registration and Verification:
Implement an electronic check-in system that prompts for complete patient information and insurance details.
Train staff to verify insurance eligibility on each visit using real-time verification tools.
2) Service Documentation:
Utilize electronic health records (EHR) with integrated coding tools that suggest appropriate codes based on documentation.
Establish a standardized documentation process and conduct periodic audits to ensure compliance.
3) Claim Creation:
Use a practice management system that integrates with your EHR for seamless transfer of information.
Implement a checklist for claim creation to verify accuracy.
4) Claim Scrubbing:
Invest in claim scrubbing software to review claims for errors and inconsistencies.
Schedule a final manual review by a trained billing specialist.
5) Claim Submission:
Submit claims electronically to expedite processing and use a reliable clearinghouse for management.
Set up automatic alerts to confirm submission and track claim status.
6) Claims Tracking and Follow-Up:
Assign a dedicated staff member to monitor claim statuses daily and address issues promptly.
Develop a standard operating procedure for handling rejections, including timelines for resubmission.
7) Payment Posting:
Automate payment posting to reduce manual errors and reconcile payments with EOBs.
Conduct monthly audits to verify payment accuracy.
8) Patient Billing (if applicable):
Generate patient statements promptly and use a clear, easy-to-understand format.
Implement an online payment portal and automated reminders for outstanding balances.
Key Takeaways!
By following these recommendations, you can enhance the efficiency and accuracy of your claim filing process, leading to timely payments and improved financial health for your practice.
Regular staff training, use of technology, and diligent monitoring are essential components in maintaining a smooth and effective claim filing process.
