Take a Team Approach to Correct Reimbursement
A group effort recoups the most money for your physician.
By Shreka D. Rogers, CPC, CMRS
Physicians expect to be paid for the services they provide; however, the reality today is many physicians receive only 35 cents per dollar for performed procedures. Accordingly, accurate coding and a skilled patient accounting staff must work together to ensure all deserved reimbursement is recovered. Here are a few tips to get you started.
¡ Be familiar with your market when negotiating contracts. Contract with insurance companies who insure the most members in your region. This is especially vital for specialty practices.
¡ Complete credentialing prior to providers performing services. When timely credentialing does not take place, it stunts reimbursement.
¡ Have an experienced person negotiate your contracts. It can be the difference between outstanding, fair, or poor reimbursement.
¡ Have skilled front desk staff who are knowledgeable about insurance requirements.
¡ Verify patient insurance benefits prior to
¡ Collect accurate information from patients, such as demographics, updated insurance, and additional information that may be necessary.
¡ Collect co-pays upfront. Some patients prefer providers to bill them for co-pays. Explain to patients co-pays are a part of the insurance carrier contract and should be paid at the time of service, in line with contracted benefits he or she chooses.
¡ Timely completion of medical records is necessary to guarantee procedures can be coded and billed in a timely manner.
¡ Clear provider documentation is vital to accurate coding.
¡ Open communication with physicians and coders regarding documentation is crucial.
¡ Forward denials to account representatives/collections staff when payments are posted, so they can inquire why certain claims were denied or not reimbursed properly.
¡ Use a consistent approach with denials. After a denial determination has been made, use proper action to get the claim paid. Contact the insurance carrier regarding a denial, or set in motion a claim appeal. Create follow-up tasks to ensure timely and appropriate adjudication.
¡ Target accounts receivable. Ensure insurance carriers have received the claims. Electronic claims filing is a must in this respect. This aids in forecasting when a claim will be reimbursed.
¡ Realize that appeals are more important than ever. Insurance carriers have been known to deny line items on claims incorrectly. A knowledgeable person should be assigned to follow up on this task. It takes proficiency, determination, and enthusiasm to accomplish proper claims adjudication.
¡ Audit claims. This is crucial to ensure accurate payment for procedures. This information should be conveyed to the individual who performs contract negotiations for your practice.
These tips are only a snapshot of what you can do to create a remarkable reimbursement program for your physician practice. With a solid foundation for reimbursement, a thriving practice can be built to weather the storms associated with the steady decline of reimbursement.
Shreka D. Rogers, CPC, CCP, has 16 years of health care experience. She is business and coding manager of Howell Allen Clinic and Saint Thomas Outpatient Neurosurgical Center, where she oversees a staff of conscientious coders, as well as accomplished medical records and patient accounting teams. Shreka is 2009 president of the Nashville, Tenn. chapter.
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