Dont Hold Your Breath
Face Reimbursement Hurdles Now
BY JEFF RINEAR AND JEAN PAPIN
With all the changes happening with reimbursements in 2015 providers are forced to focus on more facets of the revenue cycle than ever before. To help you wade through some of the biggest challenges we will identify the biggest hurdles and provide ways to help you plan accordingly.
The Price of Delay
Never before have providers faced so many challenges to their reimbursement structures.
Of course at the forefront in everyones mind is the switch to the International Classification of Diseases (ICD)-10 coming this October. Instead of holding your breath waiting for another rollback take time to prepare for these changes with your staff members to eliminate any lag during the transition.
In addition Medicare updates will prove to be a worthy hurdle for organizations that arent prepared. Medicare Physician Quality Reporting System (PQRS) and Meaningful Use penalties will most certainly impact reimbursement this year if they havent already. While you cant undo any penalties incurred in 2014 steps can be taken to reduce or even eliminate future penalties associated with these initiatives with the right planning. One of our clients a 100-plus member primary care practice is revisiting provider education in PQRS requirements after experiencing the 1.5 percent reimbursement reduction this year. They recognize this is something they should have tackled last year before the penalty kicked in.
Potentially one of the most impactful changes happening this year is this Aprils 21 percent drop in the Medicare fee schedule pending congressional intervention. This means that for every 10 percent of patients who have Medicare coverage income would drop approximately 2.1 percent. To further put this into perspective if a practice sees 25 percent Medicare patients income would decrease by 5.25 percent!
In addition many commercial contracts such as Anthem or Humana are also strongly tied to Medicare rates. Meaning if Medicare rates drop then a providers commercial income will drop by the same amount. For example if 60 percent of your practice is comprised of commercial plus Medicare patients income would drop by 12.6 percent.
To safeguard against any surprises prepare a financial overview. Per Medicares recommendations a line of credit should be opened to minimize the impact on cash flow.
Finally as we begin to see more and more high-deductible health plans its important have a game plan in place that enables you to collect payments while the patient is still in office. Eligibility tools are particularly useful in this process.
Lower Costs Reduce Denials
The ultimate goal and also the biggest challenge for every office is to have clean claims sent out on the first submission. To do this effectively you need to know how denials are trending and make sure that all critical information is included (authorizations modifiers and necessary documentation such as Clinical Laboratory Improvement Amendments [CLIA] and National Drug Codes [NDC] numbers).
A few foundational steps will also help reduce the number of denials. For example before services are rendered referrals and authorizations should be in place. Additionally draft business rules and policies for each plan so that medical necessity is in place for each claim. One pain center client of ours changed their front-office policy regarding procuring authorizations for a specific range of services and saw their approved claims rate increase by 30 percent!
Cut the Fat
While patient care should always be top priority be knowledgeable about what is happening in your revenue cycle management processes to uncover potential inefficiencies.
One example that we see every day occurs when providers administer vaccines or injections yet forget to charge for the administration of that drug/vaccine. Administration is an often overlooked separate billable procedure. You can easily prevent this by defining clear policies for vaccines or injections and implementing automated procedures as well as solid business policies to overcome payment hurdles encountered with insurance companies and government entities. For example one large pediatric provider programmed their electronic medical records (EMR) to hard stop when vaccine codes were not entered appropriately; they have experienced a nearly 50 percent increase in reimbursement for these services now that charges are being captured correctly.
Take Some Aspirin
Auditing the charge process is key to stopping missed payment opportunities such as the example we provided above. Here are a few tools that are easy to implement and will prevent headaches in the long run.
- Automated patient reminders and confirmations
- Electronic eligibility checking before insurance coverage is established
- Established procedures for claims processing for the practice billing staff
- Use of advanced rules engine to scrub claims
- Electronic payment posting
Another of our primary care clients implemented electronic eligibility verification and experienced a 20 percent improvement in their clean claims rate.
Do you see any areas for improvement in your organization? While these changes may seem like luxuries they will improve patient visit efficiency increase profitability trim keying errors and reduce denials.
Streamline for Peace of Mind
For providers struggling with revenue cycle challenges an outsourced billing partner is often a worthwhile engagement. The automated claims processing they provide allows for fast accounts receivable turnaround with the added benefit of staying on top of all regulatory and policy changes that sometimes fall through the cracks.
Its time to make 2015 a year of improved efficiency. No more wasted time or leaving money on the table from denials or processing errors even in the face of the fundamental hurdles were facing.
Jeff Rinear is President of The Consult (TCI) and Jean Papin is Billing Operations Manager TCI in Cincinnati OH a privately owned and operated firm providing business-related services to providers and healthcare organizations nationwide.