As the Pain Management Space continues to transform right before our eyes and only those who are making the key adjustments to their clinics will win the long term game.
We work with a number of Pain Clinics across the country and get to see not only the business process that works but also can follow the learn from the ones that don't work.
How to WIN the Revenue Cycle game in 2022
We have put together the top 5 areas that you can address or review within your own clinic. As the write this, please know what this information is always changing. If you find yourself needing to speak with someone who can review any of these topics for our own facility, you can reach out to us at 888.888.8888.
Become Experts at Eligibility and Benefit Verification
The practice needs to absolutely make sure that we have the right billing information and that it is validated well within the DOS. Just making sure that the patient is eligible may not be enough for a pain management ASC center. We need to ensure – among others – that
The service is covered within the patient’s plan when performed in a ASC setting
The frequency of service is under the LCD (or similar applicable) limitations
The patient’s estimated cost-share is discussed and collected before the service
Missing out on any one of these will mean that you could end up with a lot less payout for services performed.
2. Insurance Billing – Timeliness and Accuracy
Example 1) The goal of every claim is to bill it fast and get paid on the first insurance 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 any 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, you could be setting yourselves up for a certain denial, which will cause the following
-having to do a claim addendum
-sending out a corrected claim with the correct documentation
-long back and forth communications with the insurance company
Example 2) 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 our clients 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.
3. Knowing What to Expect From Your Payers
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 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 variances come 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 your practice will continue to leak money over time.
Proper reporting can fix this, but you have to ensure you have a proper view setup to be able to identify the areas of concern when payments are short. We fix this with our PowerBi dashboards.
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4. Having an Aggressive AR Approach:
Businesses today want to be as lean as possible, while still maximizing collections and profits and hence, the need to bring proper intelligence into the equation. Examples,
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 much sooner – because if it is indeed not on file, we can resubmit readily and save valuable time.
Using Clearing house denial workgroups can help identify a denial much faster and allow the clinic to fix in 24-48 hours compared to the archaic method of working items through regular AR allocation.
Not missing critical follow-up promises: If 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.
HEALTHX can help smarten your AR operations….
5. 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 analyze available data to make better decisions and bring about more meaningful and impactful changes to their Operations.