Medical Practices Struggle to Collect Payments Due to New Payer Tactics

Over the past month or so, we've seen so many side effects from insurance companies both opting in to provide insurance through the health insurance exchanges and opting out.  Those that opted in are losing a lot of money right now due to the low number of enrollees.  Those that opted out are also losing a lot of money because they lost several of their clients when they dropped them from enrollment. 

Here's how those side effects are trickling down to medical practices: 1. Insurance companies that typically paid you within 15 days to 20 days are now holding onto that money and making more money in interest on it, leaving your cash flow suffering.  I'm also finding that they you are not paying until you call asking where that money is. 2. Insurance companies are dropping claims stating, “We never received those dates” when the two dates before and the two dates after, all within the same batch, have been paid.  This is resulting in your billing department having to follow up on all claims older than 30 days. 3. Insurance companies are creating narrow networks and patients are having difficulty finding in-network providers.  This means that many of your patients may have to pay out of network rates.  They not only have high deductibles, they also have high premiums. 4. Insurance companies are hiring outsourced auditors to review every single claim they have paid you.  If they find one error, they're coming after that money.  I once had to write a refund check for 4 cents.  Yes, 4 cents.  This can be devastating to your bank account. Essentially, these changes mean that your practice will be more and more strapped for basic cash flow.  Payroll, expenses, administrative time chasing this money down, are all a drain to your business.   Your businesses accounts receivable should be considered an asset until it starts costing your more to obtain that money than you are paid for that claim.  Here are some tips you can implement right now to help you get through this new “norm.” 1. Be sure your billing staff is calling on claims older than 30 days to 45 days if you are typically paid sooner. 2. Your billing department should have access to your clearinghouse website and be able to prove that all claims were sent on time. 3. Start keeping a list of alpha-prefixes or some type of identifier that shows it's a newer plan and you are perhaps not in network. When calling and verifying, do not assume you are in network.  Ask the rep: “Are we in network with this plan?” and if you are not, ask for out of network benefits.  I'm also seeing that many specialties are not a plan benefit, so even if you are in network, your specialty may not be covered.  In this case, you will need to turn the patient into a cash paying patient. 
Keep your eye on your accounts receivable and your bank account.  It is imperative that you own this area of your business in this volatile insurance fiasco.

Article By P.j. Cloud-moulds from Physicians Practice http://www.physicianspractice.com/blog/medical-practices-struggle-collect-payments-due-new-payer-tactics?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=18032014

Six ICD-10 Questions for Your Medical Claims Clearinghouse

By Lucien W. Roberts courtesy of Physicians Practice

It's September, and you've been busy since February preparing for ICD-10. No? Well, fortunately you still have 12 months to get ready. One key partner in your preparations should be your medical claims clearinghouse.

One of the things I learned from the HIPAA 5010 transition was that it hurt cash flow in way too many practices. I had the chance to observe two practices that had the same practice management system, the same payers, but different clearinghouses. One practice was a month down on cash flow well into the spring; the other had no cash flow disruption at all.

A very few clearinghouses made the 5010 transition seamless for practices; accepting both 4010- and 5010-formatted claims and then converting them, as necessary, on a payer-by-payer basis.  I never appreciated the value of a reliable clearinghouse partner until the 5010 transition.

So how does that lesson apply to the ICD-10 transition? As with 5010, your practice's cash flow will be at risk during the ICD-10 transition. Here are six questions to ask your clearinghouse as you prepare your practice for ICD-10.

1. Our practice suffered a disruption of cash flow during the 5010 transition. What will you do differently with ICD-10 to prevent a repeat performance?

(This is an optional question for practices that suffered during the 5010 transition. If you do not like the answer you get, consider moving to a clearinghouse whose 5010 performance was stronger.)

2. Would you please run a report of claims rejections and denials by ICD-9 code?

(And while you're at it, please provide guidance on how to prevent these errors.)

3. Would you run a similar report by payer?

(Such a report will give you a good basis for meeting with your key payers and discussing their ICD-10 conversion plans.)

4. Please run a report that identifies the "generic" codes each provider uses regularly.

(Generic ICD-9 codes (like 250.00 for Type II diabetes) are most likely to be denied by payers going forward. These codes should be your first priority as you commence ICD-9 to ICD-10 mapping.)

5. Could you share advice on mapping my superbill from ICD-9 to ICD-10?

(Coding remains each provider's responsibility. However, your clearinghouse may be helpful in this critical exercise.)

6. Could you share the progress of your discussions with my practice management vendor and my payers? When can we start sending test claims?

(Mapping from ICD-9 to ICD-10 is not an exact code-for-code proposition. Prudent practices will map — test — refine — test — refine their coding well before they submit their first real ICD-10 claim on Oct. 1, 2014.)

Post ICD-10 performance evaluation

TK Software of Carmel, Ind., is one clearinghouse whose clients were unaffected by the 5010 transition. TK Software's managing partner, Matt Behringer, shared their post-ICD-10 plans: "A post ICD-10 performance evaluation is critical," Behringer says. "Your clearinghouse should be able to create reports that show encounters, dollars billed, dollars rejected, and/or denied [claims] per day for each provider, pre- and post-ICD-10."

I agree. Ongoing cash flow in an ICD-10 world will require diligence and corrective education in the days and months following Oct. 1, 2014. A reliable clearinghouse partner helps, but it remains incumbent upon practices to begin their ICD-10 preparations now.

Article by: Lucien W. Roberts, III, MHA, FACMPE, is a consultant and a former practice administrator. For the past 20 years, he has worked in and consulted with physician practices in areas such as compliance, physician compensation, negotiations, strategic planning, and billing/collections. He can be reached at Lucien.roberts@yahoo.com.

Article courtesy of http://www.physicianspractice.com/icd-10/six-icd-10-questions-your-medical-claims-clearinghouse?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=19092013

Choosing the Right Clearinghouse - Five Essential Qualities

An article by Bill Marvin from the July/August issue of HBMA Billing (www.hbma.org).
In the healthcare billing industry, the clearinghouse you work with has a huge impact on your business. The more efficiently your clearinghouse processes and returns your information, the faster you and your clients will get paid and the more payments you will collect. Therefore, knowing the right qualities to look for in a clearinghouse is crucial to the success of your business.

To gain insight into what billing services need from a clearinghouse, I interviewed Kevin Milam, owner of a company that does billing, consulting, and accrediting for clients across several states. We came up with five essential qualities to look for when researching clearinghouses to ensure that you are making the best decision for your business and your clients.

1. Knowledgeable and Immediate Customer Support

Having access to a knowledgeable, responsive customer service team is critical in any industry. For a billing service, waiting multiple days for an issue to be resolved can result in delayed payment, so choose a clearinghouse that allows you to log an inquiry 24/7 and that will respond to you within 24 hours. How can you tell for sure if a clearinghouse offers high-quality customer support? "Generally, if you receive immediate acknowledgement and responses to inquiries while you're researching a clearinghouse, you likely will receive the same treatment as a customer," says Kevin. Also, review the clearinghouse's commitment to customer service hours and responses in its contract. In most contracts, these performance elements are known as Service Level Agreements (SLAs) and are contractual commitments, sometimes with penalties.

2. Quick Claim Responses (Claim Status)

Once you submit claims to your clearinghouse, you should know within minutes which claims went through and which claims need to be corrected and resubmitted. "The longer you have to wait for claim responses, the longer it takes before you can correct any errors," says Kevin. "This delays cash flow for you and your clients and potentially leaves money on the table." Clearinghouses that tie claim status back to individual claims will save you time in the submission process.

3. Consistency and Accountability with 835s

You should receive an 835 and payment within a consistent timeframe so that you can post and reconcile your payments quickly. "With clearinghouses I've used in the past, I have received 835s weeks or even months after receiving the payments," says Kevin. "There was no consistency." When you can count on receiving 835s and payments within a day or two of each other, you and your staff won't waste time tracking down delayed 835s or payments for posting and reconciliation. Furthermore, the payment trace numbers or check numbers should re-associate with the 835s so that you can reconcile the payments more efficiently.

4. Efficient Claim Information

"It's not enough to have all of the claim information in your system," says Kevin. "You need to be able to use that information efficiently across multiple staff members at the same time." For example, if you can view a summary of all claim statuses on an 835, your staff can immediately identify which payments to post and which claims to reprocess. Additionally, your staff should have the ability to update the claim statuses as they reprocess claims or post payments, so that they don't duplicate any work done on the 835. This enables you to track all claim activity from a summary report or dashboard without wasting time looking at each individual claim.

5. Usability

For a billing service, it's key to be able to train your staff to use your system, especially as your staff changes or expands. Choose a clearinghouse with easy-to-use features like human readable claim responses and 835s; detailed and customizable reports hosted in a secure, private cloud; and a minimal number of clicks required to complete your workflow. "The steps required to process claims should make sense," says Kevin. "If you can't easily train your staff to use your system, it won't benefit you."

In addition, it is important to choose a clearinghouse that is accredited by the Electronic HealthCare Network Accreditation Commission (EHNAC). Some states and many payers will require you to use an EHNAC-accredited clearinghouse.

When you research clearinghouses, be sure to speak with existing customers, whom you can ask about each of these qualities. As the industry pushes for greater efficiency, it becomes even more important for your business to save time and money. Working with a clearinghouse that has all five of these qualities will help you to simplify your day-to-day processes, increase your cash flow, and help your business and your clients' businesses thrive.

 

Courtesy of: http://www.hbma.org/news/public-news/n_choosing-the-right-clearinghouse-five-essential-qualities