Healthcare is transforming right in front of our eyes. The last 12 months have rocked the industry to the core. The ways facilities engage with patients from treatment to payment processing are changing. Pain Management Clinics are at a bigger disadvantage due to limited resources compared to bigger hospitals. Despite these setbacks we have been able to help Pain Management Clinics thrive in the new healthcare economy.
We are sharing 5 ways your facility can improve collections in 2023 and beyond.
1. Become spot-on with eligibility and benefit verification: The practice needs to absolutely make sure that we have the right medical billing information and that it is validated well within time. Just making sure that the patient is eligible may not be enough for a pain management ASC centre.
2. The service is covered in the patient’s plan when performed in the ASC setting.
3. The frequency of service is under the LCD (or similar applicable) limitations.
4. The patient’s estimated cost-share is discussed and collected before the service.
5. Missing out on any one of these will mean that we end up with a lot less for the service than we need to.
Insurance Billing – Timeliness and Accuracy
One of the most common struggles that most pain management practices is having claims sent out on time and with great documentation.
The accuracy of coding is equally paramount. Our best chance of getting paid is the first submission. And everyone – from the MA to the provider to the coder – has an important role to play. For instance, a SCS trial (which is one of the most expensive services at a pain ASC) has just 4 permissible primary ICDs [LCD Article A57023] – and unless the provider and the coder account for this during clinical documentation and coding respectively, we are setting ourselves up for a certain denial and setting off a chain of unnecessary actions….
-having to do an addendum
-sending out corrected claim
-back and forth communications with the insurance for a long period of time to justify the second submission and get it paid.
Another example is the documentation of medical necessity. This is so open-ended that payers will use it to deny even the cleanest of claims and it is then placed on the practice to establish medical necessity based on the available documentation. One good solution that has helped us counter this is to have a section dedicated to explaining the medical necessity of the procedure. It sounds simple enough but makes it easier for the payer to look for what they need without having to go through pages and pages of clinical documentation.
If time is money, then this area alone could be costing you thousands of dollars if done poorly.
Knowing what to expect from the payer for the service
This is arguably the trickiest piece of the puzzle. Why? Because most practices do not have (or do not abide by) the executed contract with the larger commercial payers.
What this translates into is a glaring inconsistency in how payers pay for the same service across patients and across timelines. Payers like BCBS, UHC and Cigna are known to vary their allowable for the same service even for the same patient at different times. The variance is usually subtle – and granted that some of the variance comes from the sub-contracts within the larger payer contract – but it all does add up and unless we know what minimum payment to expect from each, we will not be able to counter this and continue to leak money ever so often.
Proper reporting can fix this, but you have to ensure you have proper views setup to be able to identify the areas of concern when payments are short.
More Aggressive AR approach
Yes, every claim every month was an age-old adage but it is pretty much on its last leg of relevance. Businesses today want to be as lean as possible and yet maximize collections and profits and hence, the need to bring intelligence into what is being worked and how frequently it is being worked on.
1. We don’t need to wait for 30 days to find out if a Kyphoplasty claim for $50,000 was received or not. That should be done a lot sooner – because if it is indeed not on file, we can resubmit readily and save valuable time.
2. Clearing house denial workgroups can help us identify a denial as soon as it comes and enable us to work it in 24-48 hours compared to the archaic method of working items through regular AR allocation.
3. Not missing critical follow up promises: So you called on a claim and requested a copy of the cashed check and were told that it will be sent to you in 72 hrs. But you could not check back on it on the 4th day. Sounds relatable? Every such miss costs the practice valuable time and money and impacts the overall health of the business adversely.
Find how HEALTHX can help smarten your AR operations….
Bringing operational intelligence front and center with Data Analytics
One thing that has distinguished the better performers from the rest is how they have been able to use and analyse available data to make better decisions and bring about more meaningful and impactful changes to their Operations.
For a practice that does 20-odd different types of pain services – for them to know the single-most denial reason for their most denied service by their biggest payer – is just valuable information, which when utilized to effect change can help prevent their biggest denial.
Visualizing the data to create an early warning system that is relevant to your practice is one of the biggest tools that will help you stay ahead of the curve. For instance, a 2% increase in the 90+ AR over 10 days may not be much or might be a big red flag to your practice – but we will not know if we never had a trigger that the 90+ has gone up by 2%.
There you have it. Some solid advice that you can take back to your clinic and start making improvements on Day 1.
Recent Success Story: Pain Management ASC came to us with several issues are their professional and ASC billing claims. We were able to implement much of what you read today and the end result was over $4,000,000 in additional collections and the lower A/R they have ever had.