Revenue can be lost everywhere within the RCM process. CRS works with our clients to identify and fix problems to maximize their reimbursement. To help you understanding how, let’s look at where in the RCM process revenue is commonly lost.
Payer / Network Contracting
Other than Medicare and Medicaid, contracts with other payers can be negotiated yet most providers do not go through this process. They simply accept the payer’s terms leaving money on the table. Billing for non-contracted services means higher out of pocket expenses to the patient and increases denials of claims. These increase the time it takes to work claims along with other related expenses and reduces revenues. Payer contracting requires you to know exactly what your cost to treat a patient is and a smart market assessment of how the contract will impact your volumes and profitability. PT’s and OT’s learn more by clicking here. Other healthcare providers learn more by clicking here.
Few things can negatively affect provider revenues greater than a poorly credentialed practice. It needs to be in order, as all reimbursement depends on it. A credentialing specialist needs great organizational, follow up and communication skills. Familiarity with relevant contracts and persistence with busy clinicians is required. PT’s and OT’s learn more by clicking here (go to PT consulting services). Other healthcare providers learn more by clicking here.
EHR and PM System Set Up
Often time experienced practitioners and coding experts are not involved in the set up process. As a result, proper rules and protections in the utilities of your PM system are not created causing avoidable front-end edits and rejections to occur. Some providers also abuse the efficiencies gained with EHR software to the extent that those efficiencies become pitfalls that increase audit risk. Proper set up requires a strong understanding of coding and documentation requirements and a keen eye for audit risk. PT’s and OT’s learn more by clicking here. Other healthcare providers learn more by clicking here.
Believe it or not, most providers do not capture all of the applicable charges related to the services they provide to their patients. Some of this occurs from not properly documenting the patient encounter. If it’s not documented it can’t be billed and if it was billed, be prepared to refund the money. Lost charges also occur from not coding everything that is already in the documentation. PT’s and OT’s learn more by clicking here. Other healthcare providers learn more by clicking here.
In this time of fully integrated EHR and PM systems where the EHR automatically codes the encounter and the PM submits a claim with the push of a button, internal control processes are weaker than ever. The assumptions that these systems make need to be tightly defined by experts and then closely monitored for accuracy on an ongoing basis. Don’t believe everything your software vendor is telling you! Until these systems are foolproof, assuming they are flawless is foolish! Modifiers, G codes,………. We have worked with many more systems than you have and the GIGO rule holds true in every system out there; Garbage In, Garbage Out. PT’s and OT’s learn more by clicking here. Other healthcare providers learn more by clicking here.
Follow Up / Denial Management
This is the most underserved and overlooked step in the RCM process by far! CRS only submits perfectly clean claims, 99% of the time on behalf of our clients. Then how is it that we spend 50% of all the time we spend working for our clients after the claim has already been submitted?! Because that is what it takes to have 0% bad debt and average days outstanding under 30 days. Anything other than a 50/50 balance between getting claims out and getting payments in and I guarantee you are losing revenue. CRS provides expert Accounts Receivables Management Services as a stand-alone service or as an integrated part of our broader RCM services. No EHR or PM system no matter how well designed can perform this critical step in the RCM process. This step is all about the human element. Until payment models completely change, follow up will be something only skilled AR managers can do effectively. PT’s and OT’s learn more by clicking here. Other healthcare providers learn more by clicking here.
Payment posting is one area where technology has provided efficiency gains but the human element is still required. Payment posting breaks down into payments that can be electronically auto-posted and those that require manual posting. We have seen it all. Payment posting isn’t done as soon as the EOB arrives. Delays in posting cause unnecessary follow up efforts when the AR staff contact payers for payments you have already received. Payment amounts are not carefully reviewed to assure and improper payments are accepted. Posters miss incorrect payments on fee schedules, partial payments, payments based on inapplicable “usual and customary” rates and bundle payments that shouldn’t be bundled. Denied claims are not reviewed for errors and therefore are not corrected and resubmitted for payment. Payable claims are also rejected and payment posters are not familiar enough with the payer processes, guidelines and applicable reimbursement rates to prevent lost revenues. And the piece de resistance, billers adjust off these payable claims to make the AR look better. PT’s and OT’s learn more by clicking here. Other healthcare providers learn more by clicking here.
Patient collections are rapidly becoming and increasingly important part of provider revenues due to increases in patient co-pays and deductibles. Nationally the statistics on healthcare providers collecting patient balances are abysmal. As payers shift more and more costs to the end user and more and more risk to the provider, the percentage of the total reimbursement dollars falling into the patient pay column continues to increase. Without new effective strategies, policies and procedures for collecting patient balances more and more revenues are being lost. In today’s healthcare environment, how well you do with collecting patient balances can be a major determinant of your profitability. PT’s and OT’s learn more by clicking here. Other healthcare providers learn more by clicking here.
I would like to thank Certified Reimbursement Solutions LLC, for the quality of work they have done for my billing since taking over...read more
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