Osteopathic Family Physicians Need
To Fight for What is Really Owed
By Judy Capko
In these times of increased overhead and declining revenue, it’s vital for you to be sure your office is doing everything possible to get paid for everything you do. Negotiating the best contract rate of payment, proper coding and monitoring charge reporting are the first steps. This must be followed-up with billing savvy and solid reimbursement management strategies. Are you collecting what is really due to you?
Reimbursement management begins by changing the assumption that third party claims are submitted, processed and paid properly. Payers deny a significant number of electronic claims filed because of avoidable errors. They are rejected for missing or incorrect data and are denied for inappropriate or inadequate coding on the provider side. Beyond that, the payers make errors in claim payments that are sometimes overlooked by the practice.
Claims Submission
When errors are made in a claims submission, the claim is rejected and returned to the practice. It is important to examine how frequently this is occurring in your office and what the turnaround time is in getting the claim resubmitted.
When I am called into an office because of rising accounts receivables, it is often partially due to thousands of dollars of rejected or denied claims that are being ignored by a busy staff. Your processes should include setting a 48-hour turnaround standard for rejected claims and an analysis of the type of errors that are occurring. It is only then that we can educate staff and physicians in way that will result in permanent resolution.
Claims Payment
It is important that the people in your office who are responsible for handling third party payer claims payments know what your contract rate of payment is on your top 20 services. This can be easily created on a spreadsheet. The actual payment should be compared to the spreadsheet.
When there is an error in the payment (EOB) amount the explanation of benefits needs to be scrutinized, based on the itemized charges presented on the claim. When payment is less then the contracted rate or a charge is not paid, it is your job to appeal the claim.
Too often the posting is done so quickly that the payment is not analyzed and the charge adjustment on the claim is based off of the payer’s actual payment. When this occurs you have adjusted off charges that need to be appealed for further payment. You need to fight for your money.
Claims Tracers and Appeals
Payers recognize that the majority of medical practices will not notice or respond to a claims processing error. They are benefiting from their own errors. Be sure your staff has the tools, education and training to properly review claims payment and EOBs for payment errors due to claims processing by the third party payer.
Appealing a claim is an easy process and should be done as soon as you post the claim. Never allow your staff to adjust off a third party balance without verifying the claim was properly processed and paid appropriately. Delayed Claims Processing
Each month the office should run an outstanding claims report. Examine the claims that were submitted 45 days prior and begin the inquiry process. It is better, quicker and takes less staff time to batch by payer and call the insurance companies involved, but written tracers can be sent. Some billing systems can generate the tracers for you.
Continuing Education
Invest in continuing education for your entire staff. Those involved in coding, posting, billing and reimbursement management should attend workshops annually. You need to meet with the team quarterly to review internal processes and practice performance. It is your practice and your money. Make sure you are getting paid for what you do.
Judy Capko is a healthcare consultant with more than 20 years experience. Her focus is practice operations, staffing, finance and marketing. Judy is a national lecturer and has participated in ACOFP conferences. She is based in Thousand Oaks, CA and can be reached at (805) 499-9203 or e mail: judycapko@aol.com
