CASE STUDY: Medical Group, Union NJ (2 Providers)
An Internal Medicine/Primary Care office located in Union, NJ was quite overwhelmed with the overbearing costs, administrative hassles, staff issues and gross collection deficits. An administrative decision to sell the group was earnestly deliberated. With an average monthly collections between the 2 providers totaling less than $60,000 while estimated hospital based physician salary is nearly $220,000, a quick resolution was necessary. In 2011, in an attempt to save the group, ClinicSpectrum was hired by the administrative team. Immediately, imperative key issues were discovered, and a revenue maximization strategy for cost efficiency was implemented.
Step 1: Operational Restructure through Hybrid Workflow Model
ClinicSpectrum immediately identified all the office tasks including inventory management, cleaning of exam rooms, scanning of documents, appointment confirmation, eligibility services, preparing patient in exam room before physician walks in, and many others. We assigned those tasks/activities between LOCAL EMPLOYEES in the office and OFFSHORE employees in our back-office operation. Our back-office employees took over eligibility verification, indexing of scanned documents; follow up on outstanding claims, transcription services, appointment confirmation, missed appointments management and procedure recalls. The group’s local team members were then separated into an administrative team, billing team and clinical team combined with DAILY REPORTING to build self-accountability.
RESULT: With the above planning in place the practice is running smoothly and seeing 55+ patients’ on a daily basis without depending on an “Individual Team” member to run the office. Step 1 took care of operational efficiency and cost reduction through our back office team members.
Step 2: Medically Necessary Tests/Procedures for better Outcomes and Risk Management
ClinicSpectrum introduced a concept of collaborative medicine by joining an IPA (Independent Physician Association) which has turned into an ACO now. By joining an IPA, we participated in several incentive programs for Risk Management and reducing cost of care for payers. We created a clinical team that went through each patient’s clinical notes. Based on medical necessity and evidence based medicine we recommended TESTS/Procedures that were urgently needed. This resulted into better care for patients. Utilization of clinical resources/teams and diagnostic equipment made a difference in patients’ lives and saved money for Insurance companies.
RESULT: The implementation of Step 2 has resulted in significant revenue growth averaging an additional $30,000 per month over the last 4 years. At present the practice collects $1.1M per year.
Step 3: Monthly Audit
Nothing is taken for granted. Every task/office function gets audited randomly across the practice. A knowledgeable audit team focuses on the following areas: End of week supplies inventory check, daily closing report for copay/co-Insurance/deductibles, outstanding balances, patient clinical non-compliance, reminders for tests/procedures, follow up with insurance companies with outstanding claims, medical necessity compliances, proper documentation, complaint resolution and voice message tracking.
RESULT: Efficient checks and balances mechanism in place lessened errors, and improved efficiency.
The healthcare landscape has changed, and one of the biggest changes is the growing financial responsibility of patients with high deductibles that require them to pay physician practices for services. This is an area where practices are struggling to collect the revenue they are entitled.
In fact, practices are generating up to 30 to 40 percent of their revenue from patients who have high-deductible insurance coverage. Failing to check patient eligibility and deductibles can increase denials, negatively impact cash flow and profitability.
One solution is to improve eligibility checking using the following best practices:
-Check patient eligibility 48 to 72 hours in advance of scheduled visit using one of these three methods:
- Business-to-business (B2B) verification, which enables practices to electronically check patient eligibility using electronic data interchange (EDI) via their electronic health record (EHR) and practice management solutions.
- Look up patient eligibility on payer websites.
- Call payers to determine eligibility for more complex scenarios, such as coverage of particular procedures and services, determining calendar year maximum coverage, or if services are covered if they take place in an office or diagnostic centre. Clearinghouses do not provide these details, so calling the payer is necessary for these scenarios.
-Determine patient financial responsibilities – high deductibles, out-of-pocket limits, then counsel patients about their financial responsibilities before service delivery, educating them on how much they’ll need to pay and when.
-Determine co-pays and collect before service delivery.
Yet, even when doing this, there are still potential pitfalls, such as changes in eligibility due to employee termination of patient or primary insured, unpaid premiums, and nuances in dependent coverage.
If all of this sounds like a lot of work, it’s because it is. This isn’t to say that practice managers/administrators are unable to do their jobs. It’s just that sometimes they need some help and better tools. However, not performing these tasks can increase denials, as well as impact cash flow and profitability.
In our next post we will examine ways to overcome these challenges.
Did you know that between 2009 and 2012, insurance denials for claims for reasons like inclusive procedures, not meeting medical necessity, required medical documentation, among others, has increased by almost 37 percent? Additionally, did you know on average, 32 to 35 percent of claims can go unaddressed for lengthy periods of time costing practices real money? Should we even mention patient responsibility for one claim visit has increased from approximately $12 to $30 on average?
It’s as if getting money in the door for your practice has become increasingly impossible. If it’s not one thing keeping you from healthy revenue, it’s another.
While we at ClinicSpectrum offer a number of easy and comprehensive ways for you to streamline the accounts receivable process (there is help!), we also want to take a moment to inform you of some of the common ways practices lose money, and to laugh at the hilarity and sometimes sad instances when claims get denied or patients won’t pay their remaining responsibility.
And so we present to you the top 3 silliest and needless ways to lose money in the A/R process:
- Following up with patients on their owed amount following insurance collection, and even alerting credit agencies to past-due balances is about as fun as a cross fit class. It’s just plain exhausting. With patient deductibles increasingly susceptible to larger deductible amounts with certain aspects of the Affordable Care Act (ACA), it’s no surprise that many patients get sticker shock when they receive a bill. Pair this with a lack of patient education on their responsibility before services are rendered and you’re likely to end up with a lot of “I’m not paying this.” Some people even get so emphatic that they write entire blog entries on how they simply won’t comply with Obamacare. Yikes.
Don’t lose money in the patient responsibility collection piece of accounts receivable. Educate your patients about their responsibilities before they receive a bill they might not be able to afford in full at the time. ClinicSpectrum’s Eligibility Verification can help in this area.
- We have heard terrible stories from our customers prior to our engagement, of the slightest minutia of information being listed incorrectly on a claim. These small errors, often credited to a busy office and innocent human error, can cost your practice time and money. We’ve even heard claims going unsettled for nearly one year because of a spelling error, misdiagnosis or number listed incorrectly.
To the rescue! ClinicSpectrum also has knowledgeable staff, products and solutions to make sure headaches like this don’t happen.
- You call, call, and call – and call one more time – but the insurance company is just plain UNAVAILABLE to help you on a claim. We can bet you have one thousand better things to do during your busy day than to remain ear attached to the phone hitting redial or trying to navigate complicated automated phone system menus.
ClinicSpectrum can easily save you from all of this hassle. We have a proven insurance claims follow-up process divided into three methods:
- Online Claims Follow-Up – Using various Insurance company websites and internet payer portals, we check on the status of outstanding claims.
- Automated Claims Follow-Up (IVR) – By calling Insurance companies directly, an Interactive Voice response system will give the status of unpaid claims.
- Insurance Company Representative – If necessary, calling a “live” Insurance company representative will give us a more detailed reason for claim denials when such information is not available from either websites or Automated phone systems.
Is that a collective sigh of relief we hear?
Don’t lose money when it comes to collecting money owed to your practice. Contact us for an assessment. We want to help you get money in the door.
Tracking down past-due balances and claim denials from insurance companies and patients is tedious work and consumes precious time that many physician practices simply don’t have no matter if you have two or ten people on staff for front and back office work. This is also an area that can become incredibly costly for practices. We don’t have to tell you twice that if money isn’t coming in the door exactly when balances are due, the likelihood of capturing those balances lessens as time goes on.
Among other time-consuming areas physician and clinical practices must handle on a daily and weekly basis, this is an area of a practice that is especially ideal for outsourcing. Specialized organizations can devote the proper time to the process and have the expertise to maximize collections.
An outsourced accounts receivable collections process begins after the physician’s billing staff creates and sends insurance claims (electronic/paper claims or manual HCFA forms) to various insurance companies. Follow up on electronic claims should begin 10 days after submission, and paper/ Health Care Financing Administration (HCFA) claims follow up should begin 20 to 45 days after submission.
The follow-up process is divided into three methods:
- Online Claims Follow-Up – Using various Insurance company websites and internet payer portals, the service provider checks on the status of outstanding claims.
- Automated Claims Follow-Up – By calling Insurance companies directly, an interactive voice response system (IVR) will give the status of unpaid claims.
- Insurance Company Representative – If necessary, calling a “live” insurance company representative can provide a more detailed reason for claim denials when such information is not available from either websites or automated phone systems.
These outsourced services can help practices delegate specific time-consuming tasks and maximize their collections to boost the bottom line. Get money flowing in the door today – don’t wait.
ClinicSpectrum: How long have you been using ClinicSpectrum?
Nelly: Union County Cardiology has been using the full suite for about 10 years now. We began using billing services and expanded the relationship to use credentialing and billing services.
CS: What do you like the most?
N: That’s easy. I enjoy that I don’t even have to think about eligibility—all of our patients are confirmed to have insurance prior to their appointment, which considerably cuts down on A/R follow-up and denials management. My monthly headaches have been greatly reduced!
CS: What was the key factor to your decision to implement CS solutions?
N: Time is incredibly important. Saving time means getting paid and settling claims faster, allowing us more time to work on the most important part of the business, our patients. Anything that is proven to save me time is a winner in my book.
When we were doing entire process ourselves time was 30 minutes and cost was $8 to 10 per claim. With ClinicSpectrum, the cost of denials came down to $4 to $5 per claim.
CS: What are the 3 biggest challenges faced by physician’s practices?
N: While I wouldn’t have stayed in this career for so long if I truly didn’t enjoy, the fact is, like with any company, there are daily challenges that the team running a practice faces. From my perspective, I’d have to say that the three biggest challenges are managing efficient operations, staying up to date with all the changes necessitated by healthcare reform, and lastly, and in part linked to the changes in healthcare reform, is managing patient eligibility.
The good news is that there are solutions that greatly aid us in addressing these challenges. ClinicSpectrum’s hybrid workflow model lends itself to efficient operations, by coupling automation and outsourced human follow-up, allowing us to make the highest profit. At the same time, it’s my responsibility to be informed of all reform changes, which can affect every part of our business.
Profitability is hugely determined by adherence to the frequent healthcare reform mandates, so it’s imperative that someone in my position remains aware of all changes.
With automated eligibility, ClinicSpectrum saved us lot of surprises.
For example, eligibility has become a huge challenge due to healthcare reform. An influx of eligible patients, in addition to changes in health plan coverage for patients that were already insured, has left many practices scrambling. Knowing that a patient’s eligibility has been confirmed in advance allows us to secure payment easily and transparently.
CS: What has been the biggest aid for you in tackling these challenges?
N: By switching to automated eligibility verification, we save an average of $3,700 per year, per physician, and by submitting electronic claims rather than paper claims, we save an average of $23,126 per year, per physician, which helps us to still turn a profit and manage efficient operations.
Outsourcing claims and eligibility work is also a huge help in taking on these challenges. My team is able to oversee operations without having to spend the time to do the paperwork and follow-up as well.
CS: What were you looking for in an outsourcing company?
N: We had a few ideal attributes in mind when we began the search for an outsourcing company. We needed a company that could handle claims, authorizations and eligibility—we didn’t want to work with multiple vendors, so instead sought a one-stop-shop. Making sure the company is accountable and accessible is also a factor. Claims processing is often a 24/7 endeavor and I wanted to work with a company that I knew would take my calls and emails in a timely manner. Lastly, ClinicSpectrum’s hybrid workflow model of both automated and outsourced human follow-up offered something that its competitors didn’t deliver.
ClinicSpectrum offers all of these services and scrubs up the claims so minimal interaction is needed by my administrative staff, which allows us to spend valuable time with patients that would have otherwise been spent on administrative work.
CS: What are some challenges of outsourcing?
N: Our patient’s privacy is of the utmost importance to us and outsourcing can put that at risk. We prioritize that our patient data is safe and secure and that the company we outsource to remains HIPAA compliant.
Nelly Gamboa is administrator for Union County Cardiology Associates in Union, N.J.
This is part two of a two-part post that evaluates what is delegated credentialing and why healthcare provider organizations should consider it.
As explained in the first post of this two-part series, delegated credentialing is an opportunity for large provider organizations to take matters into their own hands, streamline processes and realize substantial benefits. These include getting providers credentialed quicker so they can generate revenue and expand clinical bandwidth.
So, how do organizations create a delegated credentialing services process? It entails establishing processes, as well as implementing tools to assist with workflow and manage the flow of data.
Key processes to implement include:
- Adopting Credentialing Standards — The National Committee for Quality Assurance (NCQA) has already established standards for payers, as has the Joint Commission for providers. Standards from both organizations should be adopted, as well as any specific standards from regional payers.
- Establish a Review Process — Create a committee to define processes and review provider credentialing.
- Conduct Ongoing Monitor — Develop processes to continually monitor work quality.
- Re-Credentialing — Create processes to easily re-credential providers on an ongoing basis.
- Create Agreements with Payers — Delegated credentialing agreements need to be established, clearly stating structure and metrics, including:
- Outlining the responsibilities of the payer and delegated entity.
- Detailing metrics of how the payer can define and assess performance.
- Developing ongoing oversight processes.
Accomplishing these processes requires sophisticated credentialing software that includes:
- Analytics and reporting
- Dashboard presentations and milestone tracking
- Demographic import features
- Document management
- Reminders and notifications
- Task management and assignment features
A key resource to assist with delegated credentialing programs is the Healthcare Billing and Management Association (HBMA). The organization has a number of useful resources that expound on the above in further detail.
Author Julia Solooki is a board member of the HBMA Education Committee.
Last week we wrote a brief overview of credentialing dashboards and several people contacted us with questions about additional dashboard capabilities. To address some of those questions, we’re highlighting some other important dashboard capabilities in this week’s post. Below are several key capabilities to look for when evaluating the dashboard components of credentialing solutions.
Milestones — Dashboards also need to display progress toward, or the completion of, key milestones so users can view specific activities within the credentialing process. This enables users to quickly know what’s completed, needs to be done, is past due, and what are the new tasks that are entering the process.
Drill-Down Capabilities — An overview status of processes is valuable, but users typically need more information. Drill-down capabilities allow users to click on elements of the dashboard to display specifics, whether it’s information about individual providers, payers, or other elements of the process. This enables users to efficiently get the information they need within one or two clicks.
The Ability to View Tasks and Processes from Different Perspectives — Not all users of the dashboard are looking for the same type of information. Some may be interested in looking payer-specific details, while others are more focused on working on tasks related to individual providers. The dashboard needs to accommodate these perspectives in its display to improve staff efficiency and improved workflow. For example:
- Payer Information — Sections of the dashboard should display payer-related information, such as payer contact details, insurance PDF forms specific to the payer, web links, as well as counts of providers with insurance and their credentialing status.
- Provider Information — Other sections of the dashboard need to display provider-specific information, such as the number of providers being credentialed and the status of specific tasks within the process. Drill-down capabilities within the section of the dashboard should enable the viewing of details, including in-depth provider profiles that include all credentialing-related information, as well as the wealth of information imported from the Council for Affordable Quality Healthcare (CAQH).
Specialized Capabilities — It’s important for dashboards to be user friendly and include features that make it easier for the staff to complete their jobs. Leading credentialing solutions include advanced features such as the ability to easily attach documents to records within screens, and capabilities to upload information from other data sources (e.g., CAQH and others). These capabilities reduce data entry, and make documents easier to find.
With dashboards, everyone remains on the same page and is up-to-date with the status of tasks, which increases the efficiency and effectiveness of the credentialing process.