Maximizing Billing and Collections in the Medical Practice »

Today's shrinking physician reimbursements and rising costs for health care delivery, necessitate medical practices to have analytical tools and review processes in place to maximize their billing and collections efforts. Medical practices are experiencing challenges in collecting the reimbursements they deserve, making accurate claim submissions and appealing denied claims. Therefore, it is imperative to implement business strategies and tools to reduce claim denials, increase claim submission accuracies and improve overall business operations.

Maximizing Billing and Collections in the Medical Practice provides a systematic approach to reviewing the billing and collections process, discovering problems and preventing undue financial losses. Procedures and policies that focus on setting up billing and collection operations, payments by the patient, insurers and Medicare are highlighted. Flowcharts, graphs and tables are included to illustrate the many steps in the billing and collections process, particularly with third-party payers. The analytical approach of this book is intended to present concrete, practical information on the many details found within billing and collections.

Additional practice management resources from the AMA: Buying, Selling and Owning a Medical Practice, Integration Strategies for the Medical Practice, Managing Managed Care in the Medical Practice, Personnel Management in the Medical Practice, Starting a Medical Practice.

Doody Review Services

Reviewer:Sara M. Larch, MS, FACMPE(University of Maryland School of Medicine)
Description:This book provides an overall assessment approach to billing and collection performance and then focuses on specific areas such as patient collections and insurance collections.
Purpose:It was "written to provide analytical tools and systematic review processes." Although the book successfully offers a systematic review process, it is bit too light on the analytical tools. It describes where to obtain benchmark data but offers little data.
Audience:The book is written for physicians and their practice administrators. The authors have a lot of experience in this field.
Features:The chapter on patient collections is very good and includes helpful information on high deductible plans (HSAs, HRAs, etc.), which are a new challenge to most medical groups. The glossary is comprehensive and would be an excellent resource even if separated from the book. An appendix outlines the prompt pay statutes for each state. The book comes with a CD-ROM with seven forms in a Word format, but there are no instructions on how to use it.
Assessment:The book provides an excellent assessment process for physicians to use to evaluate their billing and collection operations. Some recommendations need more detailed information. Physicians will know which questions to ask their practice administrators, but may not have enough detail to actually complete the assessment on their own. Practice administrators will find this a helpful book to ensure they are keeping their eye on the key billing and collection functions and will encourage them to do more inquiry into their operations. Some professionals new to the field will know what to do next, but will need to spend considerably more time to complete the assessment. Other books in the field provide more benchmarking data to facilitate performance comparisons and often include template billing policies.

List of Figures, Tables, and Forms     xii
Preface     ix
Acknowledgments     xi
About the Coker Group     xiii
Getting Ready for a Self-Assessment     1
Gather Data     1
Understand Your Practice Information     3
Perform a Cursory Review     4
Summary     5
Tracking the Patient Encounter and Interviewing Front Office Staff     7
Review the Patient Encounter     7
Interview the Front Office Staff     8
Practice manager     9
Receptionist     9
Billing clerk     10
Insurance specialist     11
Summary     11
Completing the Analysis     13
Accounts Receivable     13
Collection Levels     14
Departmental Administrative Direction and Leadership     15
Operational Organization     16
Computer Systems and Associated Processes     17
Upgrade the system     18
Establish electronic claims filing     18
Use a lockbox service     18
Department Personnel Training     19
Policies and Procedures Manual     19
Adjustment Process     20
Copayment Collection     21
Patient Education     22
Staffing Levels     22
Management Reports     23
Charge Capture     23
Compliance Plan     26
Internal Controls and Cash Handling     27
Coding     28
Managed Care Information     29
Physical Facility     29
Summary     30
Setting Up Billing and Collections Operations     31
Identifying Roles and Assigning Responsibilities     31
Employing the Right People     31
Establishing Payment Policies and Fees     33
Using Performance Standards for Collectors     37
Rewarding Performance Through Bonus Plans     38
Applying Coding Knowledge     38
Summary     39
Getting Paid by the Patient     41
Collecting at the Time of Service     41
Offering Discounts for Cash Payments     43
Confirming and Gathering Copyaments     47
Recognizing the Importance of Copayments     49
Collecting from HSAs, HRAs, and Other High-Deductible Plans     50
Establishing Collection Goals     51
Making the Most of Balance Billing      53
Understanding Usury Laws and Finance Charges     57
Charging for No Shows     57
Summary     58
Getting Paid by Insurers     61
Verifying Patient Insurance     62
Using the Internet     62
Submitting a Clean Claim     63
Prebilling     64
Claims transmission     65
Payer follow-up     65
Payment posting     66
Denial management     66
Statement generation     66
Collections     66
Retrospective and concurrent review     66
Developing Payer Profiles and Analyses     68
Dealing with Slow Insurance Payers     73
Prompt pay laws     74
Recoupment of payments made by payers     74
Identifying Incorrect Payments     75
Automating Requests for Information from the Provider     76
Instituting a Follow-up System for Unpaid or Rejected Claims     77
Appealing Denied Claims     79
Using Software to File an Appeal     79
Understanding the Appeals Process     80
Urgent review     81
Appeal     81
Appeal      82
Appeal     82
Other stages     82
Filing Grievances with the State Insurance Commission     83
Summary     84
Getting Paid by Medicare     85
Know What Will and Will Not Be Paid     85
Advance Beneficiary Notice     85
Keep Up with Policy Changes     88
Submit a Clean Claim     89
Use the Medicare Appeals Process     90
First level of appeal: redetermination     90
Second level of appeal: reconsideration     90
Third level of appeal: administrative law judge     91
Fourth level of appeal: Medicare Appeals Council review     91
Final level of appeal: federal district court review     92
Use of Medicare Electronic Data Interchange     92
Pay Attention to Fraud: Compliance Should Be Part of Everyday Billing Practices     93
Summary     94
Managing Parallel Payment Systems     95
Manage on the Front End     95
Manage on the Back End     97
Capitation: Verifying Coverage and Monitoring Utilization     97
Billing for Fee-for-Service Carve-outs     99
Summary     100
Prompt Pay Statutes and Regulations      101
Resources     111
Glossary     113
Index     139