The Treasure Hunt—Keys to Unlocking Radiology Reimbursement Patricia Kroken, FACMPE, CRA Radiology Business Management Association (RBMA)

The Treasure Hunt—Keys to Unlocking Radiology Reimbursement

Patricia Kroken, FACMPE, CRARadiology Business Management Association (RBMA)

The cost of poor performance

Not unusual for a group with process inefficiencies to leave $250,000 - $500,000 on the table

Process problems raise the ante--$1 million

What would it mean if your group could increase the revenue per procedure by $3.00? $5.00?

How hard can it be?

Patient Information Entered

Insurance claim

submitted

Payment

•Front Desk•Scheduling •Billing

The Reality

Patient Information

Entered

Insurance claim

submitted

Claim denial for error

Denial assigned for follow-up

Research: pull film jacket and/or call

patient

Correct claim and resubmit

Payment

•Front Desk•Scheduling

•Billing

Where do practices lose money?

Charge captureCoding documentationClaims submission (clean claims)Insurance follow-upDenials managementPrivate pay follow-up

Charge capture

Sort and Match

Charge Entry

Coding

Demographics Radiology Reports

What happens when there is no match?

Reports with no demos

Demos with no reports

Charge capture

Usually a manual process The “stacks” build Reconciliation is very difficult

Technology is helping solve problems Document scanning Electronic “matching” Edit reports of missing information

Coding documentation

Dictation does not support codesMedical necessity denials

Need understanding of Medicare Local Coverage Determinations

Feedback from billing/coding to radiologists

Ensure credit for what was done—but if it isn’t documented, it did not happen!

Claims submission

Technology = success Edit reports Corrections of claims prior to submission

Must also be able to follow up on claims status Payor Clearinghouse Manual processes or lack of technology

problematic

Insurance follow-up

Most difficult process area to manageUsually dependent on the individual

Organization Work habits Ability to prioritize

Workloads frequently unrealistic Commercial insurance Workers comp, MVA, Medicaid

Insurance follow-up

More of an issue with hospital based practices Inherent poor quality of hospital information Denials for eligibility require

• Obtaining correct information• Refiling to the correct carrier• Completing the process within filing limits

Insurance follow-up

Insurance “correspondence” Often set aside due to workloads “Easy money”

A/R reports usually assigned by payor class Dollar amounts not necessarily

representative of work involved Number of claims

Insurance follow-up

Secrets to success Assign priorities

• Dollar amount• Age of account

– Balance working old and new A/R buckets

Work correspondence daily Document scanning

• Move work onto workstations and out of filing cabinets

Denials management

Phases of denials management Appeal of denied claims Root cause correct to reduce/eliminate

denials

Denial categories

Missing/incorrect informationPatient eligibilityPrior AuthorizationDuplicate claimsFiling deadlinesCoding

Bundled/unbundled claims Lack of specificity in ICD-9 coding Failure to “match” ICD-9 and CPT codes

Medical necessity/non-covered services

Denial trends

Internal Denial Tracking

Medical necessity16%

Duplicate10%

Missing/incorrect data35%

Other10%Pending

12%

Eligibility6%

Coding1%

Timely Filing10%

Denials management actions

Prioritize: which correction would result in the greatest impact?

Identify the source Work to correct operational problems

Training/resource issues Process “drops” Technology limitations Dictation/transcription

Drilling down denials

Distribution of denials by Type (timely filing, etc.) Site Modality Radiologist Referring physician Inpatient, outpatient, ER Time of day/day of week

Private pay follow-up

Often overlooked as revenue enhancement opportunity Patients “too expensive” to follow-up because they

“don’t pay their bills anyway”

Fertile ground for hospital-based group Patients classed as uninsured or private pay often

have insurance• Will ignore statements because “they provided that information

at the hospital”• Respond to collection letter—too late to file a claim

Passive collection processes

Passive = patient must do the work Respond to statement or letter

Series of statements mailedCollection lettersTurn to collection agency

Active collection processes work!

Initiate phone calls to hospital patients with balances in excess of $100 Do they have insurance? Would they like to pay by credit card? Would they like to be put on payment plan? Do they qualify for financial assistance?

Private pay collector can generate $250,000 or more per year May be able to set up “pass through” arrangement

with billing service

Process improvement

Radiology is comprised of a series of processes Scheduling/registration Performance of procedure Billing/collections

Correction of process problems will increase revenue…period.

To obtain copies of presentation

www.radconsultants.com

Thank you! Questions?

Patricia Kroken, FACMPE, CRA

Healthcare Resource Providers, LLC

P.O. Box 90190

Albuquerque, NM 87199

505/856-6128

pkroken@comcast.net

www.radconsultants.com