4 Charlesview Road, Suite 4, Hopedale, MA 01747
(508) 422-0231 Consulting Services
(508) 422-0233 Account Matters
Basic Rules for Getting Paid
The process of taking a new patient, providing services and getting paid sounds so simple. I mean, why shouldn’t it be? What’s so hard? Why is such a simple concept so complex? It all comes down to understanding the rules and regulations of each insurance carrier, knowing how to comply and implementing operational systems that will support your ultimate goal - getting paid from insurance and patients.
With that said, there is no doubt that each practice operations must be seamless, highly efficient and deliver exceptional customer service. This is the only way to get the bottom line outcome you are looking for - payment for the professional services you provide.
To continuously get paid for the services you render it is important to remember that every step of the process begins with the first contact with the patient – the initial phone call. The first phone call will be the patient’s first introduction to their entire experience. This is where we begin our course of action – getting basic patient demographics, insurance information, referring physician, diagnosis etc. The patient is then scheduled for an appointment, told what to bring, wear, and given other information that will make a great first visit experience.
Before a patient’s first visit, a call should be placed to their insurance carrier or checked on line to obtain benefit information – what the insurance will pay, the patient’s responsibility and confirm the referral and/or authorization information. The patient may then be contacted again to discuss their benefits and made aware of what you were told regarding their benefits and what they will be responsible for on their first visit and subsequent visits. You can recommend that they call also to confirm your information.
Rule 1 – Open lines of communication starting with first phone call.
Obtaining information and checking benefits before patient’s come in and then calling the patient back to discuss their responsibility increases your collections at time of service, lets you prepare to send clean claims and alleviates misunderstandings of the patient and insurance responsibility.
Each patient visit has to be handled with care. Whether the patient brings in preregistration forms or registers at the window, explaining what they are filling out and why they need to sign so many forms is critical to the whole process. Speaking with the patient regarding the importance of your clinic policies such as fees for cancellations, no shows or being late will help set the tone for your and their commitment to their therapy. Focusing on reaching goals and following a prescribed plan of care will strengthen the importance of their being on time and commitment to their care as well as create a high level of respect for their therapist. Raising the communication bar between the patient and the administrative and professional staff will make each visit start and end on a great note.
Rule 2 – Educate your patients.
Explain that rules are in place for their benefit – to help them reach their health care goals. Lowering cancels and no shows will improve your percent of arrival and overall cash flow. Patient’s who know your expectations will respect them and keep their focus on their therapy progress.
Internal communications between the front desk/biller/collector and the therapist is a critical part of the seamless operation. The more therapist’s know about a patients concerns,( i.e. insurance only pays for 8 visits, insurance is denying claims, co-pay too high to come 3 times a week, can only come at 7AM etc.) allows the therapist to evaluate, set goals and prepare a plan of care around the patients benefits and/or offer alternatives for meeting goals. Working together as a team allows for better solutions and payment for services that you do provide.
Rule 3 – Coordinate patient needs and established outcomes by providing an outstanding internal level of communications.
Everyone’s role in the patient experience is important. When charges for services are entered into your billing system and submitted, it is paramount that the treating therapist has approved those charges. Insurance billing regulations must be followed to insure compliance and protection of your professional license as well as avoiding audits. Professionals must be credentialed by the carriers before they can see those insured patients. The more knowledge administrators can share with therapists on billing regulations, ICD-9 and CPT coding will confirm the integrity of charges billed and insure receipt of the maximum payment allowed.
Ensuring that the therapists have documentation completed each day is critical to keeping the billing process moving forward. Any delay in documentation delays sending out claims. Whether or not you have to attach notes to a claim insurance requires that a note be completed before claims are sent out. Billers bill expecting that notes are consistently completed.
Billers should bill daily to provide for an even cash flow. Billing daily will also prompt a quick response to a denied claim thereby allowing you to fix and turn it around immediately. Billers must be qualified and experts in knowing what can and can’t be billed. They need to be insurance regulation specialists. Billers constantly trouble shoot and fix problems before claims get sent out. Your challenge is to make sure reconciliation processes are in place to validate that every patient seen is billed correctly and in compliance.
Rule 4 – Know what is being billed in your name to protect your license and provider numbers and those of the professionals who are working for you.
Have confidence in your billing staff by insuring they have been properly trained and understand the entire billing process and that supporting documentation is always completed.
It would be wrong to expect that all due diligence in sending claims is rewarded with timely payment on all claims. Claims electronically billed are usually paid on within 10 to 30 days. Any claims not sent electronically such as auto and workers compensation claims may take a bit longer – sometimes up to 45 days.
Despite all efforts, delay or denials of claims can happen. The key to not letting them age or get away from you is to consistently manage those claims. Daily checks on electronic claims that have not passed edits or have been kicked back by the insurance carrier can be addressed and sent back out immediately, usually within a day or two of the original submission. Claims sent on paper can be called on at 15 to 20 days to insure they have been received and check on when payment is due.
When you look at the accounts receivable and see unpaid claims aging to 30 days – check on those immediately. If electronic claims are aging to 30 days there is a problem – check on what you missed – correct the errors and resubmit. Whatever error caused the delay make changes to insure it doesn’t happen again.
Seeing patients and agreeing to no payment until a liability claim is settled is like playing with fire – there is no guarantee you will be paid. Some claims age over 2 or more years and when settlement time comes there may not be enough to pay you in full or worse the claim is denied and there is no payment. If you work with your patient from their first visit you may be able to come to an agreement for them to pay a self pay rate or some other agreement so you do not sit on money you may never get.
It is not wrong to expect payment from patients who self pay or owe co-pays, deductibles, co-insurance at time of service. How successful you are in collecting at time of service depends on the dedication of your staff and the education of your patients. A clear understanding at the beginning of the relationship is key to collection success.
When an office is overwhelmed with new patients, checking benefits, getting authorizations and the like, or the office is working with minimal staff, the first thing put on the back burner is the accounts receivable management. This will severely impact your accounts receivable and will show quickly once you lose momentum. A staff back-up plan and cross training is critical to maintaining a highly efficient operation.
Rule 5 – Place collections at the top of your list.
Ensuring that claims are consistently followed up on at an early stage will improve collections. Informing patients of their responsibility and holding them accountable for payment at time of services will eliminate the cost of sending statements and losing valuable income.
Communication, education, expertise and compliance are key words for providing excellent customer service and maintaining an effective and professional practice. Make sure you can rely on your staff to work as a team to deliver excellent service and care to all patients from the first visit to payment for services rendered.
Diane McCutcheon, President
DM Business Management Consulting Services, Inc.
Account Matters – Billing & Collection Services
4 Charlesview Road, Suite 4
Hopedale, MA 01747
P: 508-422-0231 F: 508-422-0234