by GroupOne’s EMR Billing Experts
GroupOne Health Source started providing EMR billing services to medical practices in 2000, one of the first firms in the country to offer such services. For medical practices that were with GroupOne for all of 2010, GroupOne’s overall net collection rate for 2010 exceeded 99.9%.
The GroupOne staff have compiled a list of seven tips the help maximize practice collections on most competent EMR systems. Most of the points assume that the EMR / EHR system is a unified system with medical records and practice management functions.
1. Submit Clean Claims.
Denied or problem claims slow down payment and are costly to resolve. Have Certified Coders review claims for accuracy. Set up and manage the EMR’s Built in Rules Engine with payer rules specific to your practice. Your system should be updated to support your payer’s contracts. Setup and mange your clearing house edits. Utilize the correct clearinghouse. Correctly setup and utilize the eligibility verification tools available in your EMR in order to verify patient eligibility and co-pays prior to patient visit. Ensure the patient demographics are complete, accurate and up-to-date. Within the EMR, configure and setup the appropriate post operative days per CPT code.
2. Appeal all denied claims (3 times if necessary).
According to GAO, 50% of all denied claims that are appealed are paid, although very few offices appeal denied claims. Almost all commercial appeal general guidelines can be classified as follows:
- Stage 1 Appeal – Nurse reviewer usually compares medical necessity to plan policy
- Stage 2 Appeal – Internal Medical Director reviews appeals/pre-determinations
- Stage 3 Appeal – External Medical Review, sometimes called ERO (External Review Option)
Usually, you have around 6 months (180 days) to request reconsideration of a claim. In each of the above steps, the insurer requires about 30 days for it to re-process the claim, for a total of 90 days. Based on experience, you get almost zero approvals at the initial review, more on the 2nd, and the greatest likelihood of approval at the final stage. However, most billing offices do not perform all stages of claim appeals (if any) before sending them to self/patient-pay or collections. This is a significant reimbursement leak in many systems. The ROI on Denial Management Software is often very positive and should be considered.
3. Patient Pay Policies
Tighten up your patient pay policies by utilizing tools within your EMR and other new technology. Take advantage of every opportunity to collect patient pay amounts in the office. Configure your EMR’s patient portal so that it functions as a collection tool. Patients should have 24/7 access to their statements, charges, outstanding balances and payment options. Furthermore, the EMR messaging system can be used to send balance reminders. It is estimated that physicians receive only fifty cents of every dollar billed to patients after they leave the office.
Currently, 25%-30% of medical practices revenue is directly related to portion of claims that is patient responsibility. The patient responsibility percentage is likely to increase in the near future. Moreover, 41.2% of patients pay for at least a portion of their expenses. The number of US consumers covered by high-deductible insurance policies increased by 64% from 2008-2010.
Tying payment for a majority of medical services to credit and debit cards at the time of service could go a long way towards speeding up payments, improving the collection rates and reducing collection expenses. Utilize the EMR Collection Model to set up and monitor patient payment plans.
4. Measure, Measure, Measure
Per an old but still accurate management adage, “You can’t manage what you don’t measure.” Review reports from the EMR that track and trend your key performance indicators, including but not limited to:
- Charges
- Receipts
- Adjustments
- Accounts Receivables
- Days in A/R
Use third party benchmarking data to compare your practice’s key benchmarks to your peers. Use these tools to compare your coding trends to those of our peers to see if you fall within acceptable norms. Automate key indicator reminders so that you automatically receive notice if your key indicators vary from pre determined parameters. Any data that varies from acceptable marks can help you pinpoint and address problem areas. Automate alerts that indicate when a payer is routinely denying claims for a given procedure code.
5. Automatically Attach CPT Codes
In-house labs and x-rays should be setup and configured correctly within your EMR so that appropriate CPT codes are automatically attached for reimbursement purposes. When tests are ordered, the appropriate progress note should be automatically updated resulting in a valid, payable claim. This process will also help ensure that all charges are captured and possibly increase practice overall revenue. In addition, most EMRs can be configured so that modifiers automatically attach to appropriate codes, lab QW and x-ray 26 or TC, which should help eliminate claim errors and denials.
6. Explosion Codes
Appropriate “explosion codes” should be setup within the EMR. The explosion codes would allow physicians to choose one code, when a combination of codes should be reported. This process saves the physician valuable time and ensures that appropriate codes are billed and that revenue opportunities are not missed.
7. Favorites List
Within the EMR, a “favorite’s list” should be created and maintained for each physician or provider. The favorite’s list should reflect the most common services performed by the specific provider. Furthermore, for most EMRs, the description names for DX and CPT codes can be customized and revised so that items and names are more meaningful and descriptive to specific provider. Some of the default descriptions are similar and can result in incorrect selections. A favorite’s list typically improves the accuracy of coding and eliminates the task of choosing the correct code from the entire CPT list. A favorite’s list can save physicians much valuable time and result in more accurate coding.
BONUS TIP: Progress notes should be marked complete and locked daily so that claims can be submitted in a timely fashion. Timely claim submission results in quicker payments, quicker claims resolutions, reduced resources tied up accounts receivables and reduced timely filing issues.
VERY IMPORTANT TIP: If transitioning to a new EMR/EHR system, make sure that the system is a unified system with complete medical records and practice management functions and data self contained in one system and database. Billing is much more efficient and effective if all data, including patient charts and financial information, is contained in one system and readily available to all. Unified systems typically allow data to flow seamlessly within the system vs. “sometimes reliable” interfaced systems. The difference in billing performance can be dramatic.
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