The unfortunate reality is that the majority of claim dollars lost to medical practices are from “self-inflicted injuries”.  While it may feel good to blame the insurance carrier or health plan and their bureaucratic, Byzantine rules, the fact is that physicians and their staff must come to grips with the reality that most of the dollars lost are through a lack of establishing proper management of their own revenue cycle, and most often, because of a decision to disregard basic business practices and payer rules.

Do you want to complain about the rules and not get paid?

Or have the money in your pocket and then complain?

Most claims dollars are lost due to:

  • Failure to identify the patient’s economic obligation before service is rendered to collect payment or guarantee payment before care is rendered.
  • Failure to submit claims in a timely manner
  • Failure to monitor the explanation of payments to identify denials or payment errors
  • Failure to resubmit initially denied claims in a timely manner with the correct information
  • Failure to appeal errors or denials in a timely manner

In reality, the failure is the physician’s, a failure to manage the revenue cycle of their practice.  It is a failure that costs big.

To eliminate the barriers that keep you from promptly receiving your hard earned money, you must make a commitment to learning how to win, and accept the responsibility for continual vigilance.  By doing so you can hold payers accountable for their performance, and in the process, achieve the funds you have legitimately earned. The reporting and other rules that have intrinsically been linked to EHR systems have been a major hindrance for small practices. Time is a precious resource, and physicians can’t always find time to fill out new reports

Payers set their own claim rules and timely filing deadlines.  They do so under their participation contract with you.  The rules are generally not spelled out in the contract, but in the payer’s “Provider Manual”, or in updates to that manual. Your contract with the payer generally includes a provision that gives them the right to issue new rules and policies and obligates you to their acceptance. Keeping up with the updates is necessary, as opportunities are missed for increased reimbursement, and plan specific rules not learned, cause an increase in denials. EHR platforms come with online scheduling, automatic bill pay and a number of other helpful tools that are beneficial to both physicians and patients.

Nearly all payers now have websites with the payer’s policies posted.  A posting is considered “notice” and the change is binding upon you.

Administrators and office managers benefiting from EHR adoption. Building schedules are simplified which reduces the number of missed appointments. Similarly, working with patients to address unpaid or outstanding bills is also more effective.

Even if you never received a provider manual, you cannot escape its obligations.  There is generally a little clause in your contract obligating you to its provisions.   If you can’t find the player’s manual, or if you are not getting the payer updates, call the plan and get a copy of the manual and get on their policy changes distribution list NOW.

Many plans now provide email alerts as to policy changes, which will automatically send you an email about payer policy changes. When combined with better clinical capacities and improved daily workflows, the benefits of EHR adoption create a portfolio of ways to improve a small practice.

Similarly, the payer’s posting of a new policy on a payer’s web site or publishing in their policy guide a policy change is binding upon you, and it could cost you.  You will need to have staff review the payer’s website on a regular basis to watch for new postings that impact your practice.

Regardless of the unreasonableness of the rules health plans create; they bind you under “contract law”.  Contract law legalizes the obligations accepted by two or more parties in a voluntary agreement.  Since the health plan wrote the contract, do you really think those terms and conditions are for your benefit or protection?  Unless the provisions of the contract conflict with state, Federal or local law or policy, you are bound to them, and the payer can enforce its contract terms.  You voluntarily entered into the agreement with the payer.  Whether or not you believe you had a choice, given the size of the payer’s market share, or what employers they insure, there is no law that obligates you to participate with any payer, therefore the relationship is voluntary. Fighting contract provisions is generally a costly and losing proposition.

So strong is the power of contract law, that the regulators have stated that they are not prepared to sit in judgment on the adequacy of documentation as to timely filing, stating “This gives rise to a question of fact which is beyond the jurisdiction of this administrative agency to resolve.  Questions of fact can only be decided in a court of law.”

More importantly, do you want to fight, or do you want to get your money?

Time is money is the old, overused adage, and in the case of claims, it’s your money.  This is where falling for the inbred excuses within the provider community comes back to haunt you.  It’s too confusing, they deny whatever they want, you can’t fight them, it’s not worth the time. Your practice needs to work its claims and receivables without allowing any time lags in getting your claim out the door, tracking its payment, appealing denials, and verifying the correctness of payment.

Vigilance is a responsibility that must be accepted by the physician and the staff.  For only by asserting your rights and knowledge of the rules, can an office protect its income and its money?  This requires an understanding of explanation of benefits/explanation of payments (EOB/EOP), as well as watching for notices of policies and changes that relate to claims.

Managing your revenue cycle means making sure that your claims process follows a process designed for your benefit, not just what is allowable by the payer.  One that always puts you in the position to press the payer for payment, using your state’s regulations as a club. That is if your state requires the payer to pay within 30 days of an electronic submission, hold them to that requirement.  Get your claims, electronically daily, and every day identify with the payer’s website any claims not paid on day 35.  If not listed, then re-submit, if listed, check where it is in the process.  If not set to be paid to you, file a complaint with your regulator of the payer.  If you have the process tight, you will have improved your cash flow, and ended the leakage of your dollars.

The blame game has no place in the operation of a medical practice, a medical business.  Blame is an easy way to dodge responsibility for an issue, a problem.

Too often practices fall into the trap of blaming the payers for everything, and in the process, ignore what should be their own responsibility and hide that responsibility from the physician.

Nathan Bradshaw

Nathan Bradshaw

contributor

Nathan Bradshaw is a health enthusiast, talented author, celebrated pod caster and a poet who is now the co-editor and imaginative contributor of health fuel with a background in collaborative care networks and artificial intelligence. Nathan Bradshaw works from a creative wellspring that shows no signs of running dry.