The Revenue Cycle Pipeline

Physician reimbursement rates have been falling while the costs of running a practice continue to increase. Squeezed financially on several fronts, medical practitioners need to ensure they are not losing substantial amounts of revenue as a result of claims that are denied or underpaid. Many providers struggle to work through backlogs of aged and denied claims which often slows cash flow and causes increased Accounts Receivable (AR) days.  Partially paid, delayed or denied payments can significantly impact a practice’s bottom line.

Information and Communication
We understand that healthcare providers need meaningful metrics to address issues that may lie within their revenue cycle pipeline.  We recommend tracking and trending denials in order to understand where issues exist.  Are four or six common lab tests causing significantly more denials than others?  Once these issues are recognized, communicate with your staff what you’ve found and develop a plan for change.  Simple changes in process and workflow can often yield big results.

First Time’s the Charm
Insurers deny claims for a variety of reasons: invalid codes were entered on the claims form, the claims form lacked a signature, the patient information provided was incomplete or inaccurate, etc.  The good news is that many of these errors are caused by human-error and therefore can be prevented by proper training.

You can reduce coding errors through additional education on correct coding procedures.  Start by maintaining up-to-date coding reference materials, and consider holding regular coding education seminars for physicians and coding staff. Identify the most common coding errors (another item to track and trend!) in your practice and make every staff member aware of them. Finally, create a system in which every claim form is reviewed to ensure it has a signature and contains appropriate supporting documentation before it is submitted to insurers.

Appeal Denied Claims
It’s important to review every claim denial and not to be too quick in accepting an insurer’s denial or underpayment of your claims. Choose one trained member of your staff to run monthly collection reports and to audit all health insurer payments and denials to determine if reimbursements or adverse determinations are accurate. For every partially paid, delayed, or denied claim, have that staffer review the insurer’s reason(s) for its actions. Gather any documents that properly support your claim for full payment and immediately resubmit your claim. Maintaining a follow-up log can help you track your progress in securing the correct payments for your services and will help you identify which insurers are more likely (and which are least likely) to make the correct/more favorable reimbursements on appeal.

Within the revenue cycle, it has never been more critical to create meaningful data, develop efficient processes and review denied claims.  It is through these activities that healthcare leaders will be able to address the issues of the revenue cycle pipeline and to create a positive environment, both financially and operationally.

For more information, please contact a member of the Bergan Paulsen Healthcare team.