Maximizing Revenues and Preparing for Payor Changes: Expert Q&A
Senior medical consultant offers guidance on how physician practices can maximize revenue and stay ahead of payors' latest attempts to cut reimbursement.
With the billing and reimbursement requirements of insurance companies becoming ever-more demanding, clinical practice finances can take a hit without consistent adherence to clearly defined protocols and vigilance regarding the frequent industry changes.
“In today's environment, practices must remain current, compliant, and efficient to respond to shrinking reimbursements, pay-for-performance payment models, stricter compliance regulations, and narrower margins,” said Valora S. Gurganious, MBA, CHBC, a senior management consultant at the medical consulting firm DoctorsManagement, LLC. In an interview with Neurology Advisor, she offered guidance on how physician practices can maximize revenue and stay ahead of payors' latest attempts to cut reimbursement.
Neurology Advisor: Currently, what are some of the most important best practices for physician offices regarding financial management and reimbursement?
Valora S. Gurganious, MBA, CHBC: Best practices begin with making sure the practice gets paid appropriately for every service it has rightfully delivered to its patients. In other words, financial management within a practice begins with revenue cycle management. This includes the following tasks:
- Practice staff verifying eligibility and benefits for services with the payor
- Obtaining prior authorization if applicable
- Proper coding and documentation by the provider that establishes clear medical necessity
- Completing and locking notes within 24 hours of date of service to permit timely submission of the claim
- Prompt posting and collection of any patient balance that remains
- Working denials for claims that were not processed by the payor
A seasoned billing manager can ensure that your revenue cycle is as brief as possible so that the practice's accounts receivable remain in check and the provider collects every dollar he or she is due.
NA: What are potential benefits of these best practices to physicians, office staff, and patients, as well as potential drawbacks of not adopting them?
Gurganious: Patients benefit from the practice's adherence to best practices in revenue cycle management because the staff confirms that the patient is covered for the service, the provider is authorized, and their insurance will honor its coverage commitment to pay for the service. That is, patients get what they pay for, and providers get paid for the services and care delivered to the patient in a timely manner. The payor also benefits from the practice following these billing and documentation protocols, which minimizes fraud and abuse by providers. Unfortunately, we find that payors frequently make the process more difficult than it should be by requiring long waits on the telephone to verify benefits or obtain authorizations–which could easily be a more automated process if payors chose. These delays and frustrations are deliberate so that they can slow payments to providers and maximize profits for their companies.
NA: What can practices do to stay current with and improve in these areas?
Gurganious: Unfortunately, payors do not intend to make it easier over time for providers to get paid for the services they provide. In fact, they appear to be making it more challenging by switching from electronic funds transfers–EFT or direct deposit–of payments to loaded debit cards. We are learning that practices are being mailed these cards with an explanation of benefits (EOB) of the applicable claims this card is paying, and the only way the practice can redeem the funds is to run it through the practice credit card machine–on which the practice may pay at least 2% of the transaction amount in merchant service fees. By issuing these cards, the payors are receiving a bonus back from the issuing bank, but the provider takes an unavoidable cut in their payment. This is unethical and unreasonable, so we urge practices to return the debit cards and insist that payments be made via EFT at virtually no transaction cost. Your billing manager should keep you updated on all of these changes that ultimately result in the payors making more and providers making less and less.
NA: In addition to these current best practices, what are some emerging trends in these areas that physicians should be aware of and potentially plan for?
Gurganious: Providers should plan for the new pay-for-performance or "value-based" payment models, known as MACRA (Medicare and CHIP Reauthorization Act) and MIPS (Merit-based Incentive Payment System).1 These new models will require practices that participate in Medicare to report on quality, outcomes, and costs of care, and CMS will evaluate their relative performance over time compared to their peers. It is budget-neutral, meaning there will be winners and losers–practices earning bonuses and others taking a reimbursement cut.
Practices should consider joining an Independent Physician Association (IPA) or an Accountable Care Organization (ACO) in their community that will facilitate data collection, reporting, and coordination of care. Your specialty Association or Academy, as well as your EHR provider can also help to position your practice to earn bonuses rather than reductions in reimbursements under this new model.
- MACRA: Delivery system reform, Medicare payment reform. Centers for Medicare and Medicaid Services website. Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html. Accessed December 22, 2016.