TIPS to improve REVENUE

Every office need an oustanding billing team. The billing team is the key to a successful revenue cycle. Here are some tips and tricks to take advantage and improve your revenue.

You are a Par or Non-par provider?

A Par providers has a contractual agreement with an insurances plan render care to eligible beneficiaries. Is important the billing team knows the details of the contract.

A Non participant provider is a physician without a contractual agreement with an insurance plan to accept an allowed amount and to render care to an eligible beneficiary. In this case the provider may decide to obtain a full payment at the time of the service. Be aware that insurance plans will cover a less amount of the claim when you are non-par provider.

How it works?

Billed amount                               $332.00

Allowed amount                            $189.89

Write off amount                           $142.02

Member responsibility                     $0.00

Reimbursement amount               $189.98

Allowable Charge: also referred to as the Allowed Amount, Approved Charge or Maximum Allowable Charge. This is the dollar amount typically considered payment-in-full by an insurance company and an associated network of healthcare providers. The Allowable Charge is typically a discounted rate rather than the actual charge. If you aren’t a network provider then you can bill the beneficiary for the amount the health insurance company will not pay.

Write-off Amount: Is the difference between the billed amount and the allowable charge, which a network provider cannot charge to a patient who belongs to a health insurance plan that utilizes the provider network. This amount is written off unless it can be billed to the patient under the payer’s rules (Non-par providers)

What to do with the claims?

• Work with payers in order to have claims processed as quickly as possible.
• Be familiar with the payers’ claim-processing procedures, including:

o   The timetables for submitting corrected claims.

o   How to resubmit corrected claims that are denied for missing or incorrect data.

• Monitor your claims by implementing a claim status monitoring program.
• Monitor claim status closely by tracking accounts receivable (A/R = the money that is owed for services rendered). The accounts receivable is made up of payments due from payers and from patients. For this reason, after claims have been accepted for processing by payers, the person in charge need to monitor their status. This require two types of information.

1.       The amount of time the payer is allowed to take to respond.

2.       How long the claim has been in process.

• Monitor the aging (how long a payer has had the claim) of claims and claim turnaround time. Just as providers have to file claims within a certain number of days after the date of service (DOS), payers also have to process claims within the claim turnaround time. The contract often specifies a time period of 30 to 60 days from claim submission. States have prompt-pay laws that obligate state-licensed insurance carriers to pay claims for both participating and nonparticipating providers within a certain time period, or incur interest penalties, fines, and lawyers’ fees. Research the law in the state where claims are being sent to determine the payment time frames and the penalty for late payers.

** TIP**

A payer may fail to pay a claim on time without providing notice that the claim has problems, or the payer may miscalculate payments due. If the problem is covered in the participation contract, the recommended procedure is to send a letter pointing this out to the payer. This notice should be sent to the plan representative identified in the contract.

•   Review EOBs to double-check the remittance data:

1. Check the patient’s Id information and date of service against the claim.

2. Verify that all billed CPT codes are listed.

3. Check the payment for each CPT against the allowed amount which may be a percentage of the usual fee. Look for discrepancies needing review.

4. Analyze the payer’s adjustment codes to locate all unpaid, downcoded, or denied claims for closer review.

5. Decide whether any items on the EOB need clarifying with the payer, and follow up as necessary.

Adjustments on the EOB means that the insurance is paying a claim or a service line differently than billed. The adjustment may be that the item is:

o   Denied

o   Zero pay (if accepted as billed but no payment is due)

o   Reduced amount (most likely paid according to the contract)

o   Less because a penalty is subtracted from the payment

** TIP**

Billing code PR (patient responsibility) on an EOB with an associate reason code indicates whether a provider may or may not bill a beneficiary for the unpaid balance of the furnished services.