Revenue Cycle Management

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What physician wants to give any money back to an insurance carrier?  Few consumers realize that unlike other business owners, physicians don’t get to set their own prices for services rendered.  Rather, they are on a “take it or leave it” reimbursement system.  So, frustration runs high when a provider is informed that there has been an overpayment on an already heavily discounted service.  These overpayments, result in credit balances.

There seems to be an uptick in the number of practices that are contacted by the State Department of Revenue and told that they are the target of a credit balance audit.  This article, Juggling the Credit Balance Dilemma, is a good overview of why this is happening and the penalties you face if you don’t resolve credit balances.  We hope you take a minute to read the article and then make sure your practice is in compliance.

Dealing with Unmet Deductibles

Unmet Deductible

Unmet deductibles challenge health care practices and interrupt cash flow.  Long gone are the days when collecting patient payables meant collecting $10 copays.  More and more patients have chosen a high deductible health plan to save on premiums and/or take advantage of health savings accounts (HSA).

Unmet Deductible This means that each patient must pay out of pocket for health care services until their deductible is met.  After that, their insurance will pay your claims.  The amount of the deductible varies from policy to policy.  However, the most common amounts range from $200 to $6,000.

Unfortunately, each new year finds patients, providers and clinic staff struggling to meet these deductibles.  Each must find an effective way to deal with the impact when deductibles reset.  Here are a few basics for improving your patient collections.

Tips to Improve Collecting Patient Deductibles

  1. Prior to the patient’s appointment verify eligibility and know what your patient will owe.  This is especially important because patients change insurances which results in changes to the deductibles.
  2. Always verify whether or not a deductible has been been met when you call to verify the patient’s insurance.
  3. Reduce front desk awkwardness and instead tell the patient why they will owe before the appointment.  Letting the patient know what they will owe is critical.  You can even do this when you place appointment reminder calls.  Patients don’t like surprises and they are being educated to understand that they will owe more than a $10 copay.
  4. Make it easy for them to pay and give them options.  Let them pay on a credit card, by cash, check, money order and even PayPal.  Make sure your staff offers to accept payment during the appointment reminder call or when they check-in or check-out.  Also, make sure that you have this payment expectations/information posted in several places in the office, including the waiting area and patient rooms.
  5. Implement a credit card on file policy whereby your patients agree to have all or some of the balance charged to their credit cards each month.  You do not want the liability of keeping their credit card information onsite, so use a certified and secure third party to retain the information.
  6. Promote your patient portal and if you don’t have one – get one.  Online payments are the way to go!  Some patients just want to go online and make a payment.
  7. Collect a flat amount in advance.  If you don’t know how much the patient will owe, then collect a flat amount.  Let the patient know that after the claim has been paid the balance will be billed to them.
  8. Inform your staff of how to collect money.  Your staff should be well-informed of all office and financial policies.  Consider providing staff with scripts to help them collect patient payments.

Time of service collections and lots of communications will help to make collecting deductibles easier and in the long run reduce everyone’s stress during ‘deductible season’.

Three Ways to Increase Your Practice Collections

How much money is your practice losing?Increase Collections

Collections are the life-blood of your practice.  Yet, doctors in the United States lose roughly $125 billion per year due to poor billing practices.  According to an MGMA study, an average practice will recover just $15.77 for every $100 owed once a patient defaults on the amount they owe to you.

Below are some ways that can be implemented in order to maximize your collections. You will find that most are fairly easy and do not require additional resources.  They do require a concentrated effort but will prove to be financially beneficial.


  1. Make sure you have a patient portal.
  2. Remember, having a patient portal isn’t enough.  You must maximize your patient portal.
  3. Make sure you have an online bill payment option.


  1. Give patients a wide variety of options for paying their bills.  Be sure to accept cash, checks, credit cards and debit cards.
  2. Encourage patients to register a credit card to keep on file with your office and make sure they enroll in an automatic pay option for their patient balances.
  3. Encourage patients to pay past account balances and current charges at the time of service.
  4. Train all staff to firmly but gently communicate with patients about patient financial responsibility issues.
  5. Be willing to refuse service to patients who do not pay.


  1. When you transition to a billing company, you get trained specialists dedicated to medical billing.
  2. Outsourcing means you don’t have to worry about personnel issues, covering vacations or ongoing training expenses.
  3. Utilizing a billing company will afford you the benefits of state-of-the-art software, up-to-date processes and key reports in a timely fashion.
  4. Dedicated efforts, working every denial, and not accepting zero payments will result in your practice getting more money faster.

Maybe all three ways won’t work for your practice or maybe you’ve already done some and that is great.  Every way that you implement will only help to increase your practice collections.




Medicare has announced they will stop using Social Security numbers for identification beginning April 2018.  The change is required by a law enacted two years ago to discourage identity theft.

The Centers for Medicare & Medicaid Services (CMS) recently updated its web page to help health care providers prepare for the change.  Medicare plans to begin mailing the new cards with unique Medicare Beneficiary Identifiers (MBI) to each person.  According to the Medicare website, the agency is just now trying to figure out the best way to mail the cards.  They plan a “wide-scale outreach” to let beneficiaries know that they need to bring their new Medicare cards when they receive medical care.


Don’t expect CMS to reach every one of your patients and don’t count on the patients to remember to bring their new card to their appointment.  Start getting the word out to your patients now.  Let you patients know that they will be getting new cards.  Let them know that they must bring this card into your office.  Include this information on your website and in your newsletter. Prepare handouts and fliers that you can leave in your waiting room and at the front desk.  Be ready to remind your patients to bring their new Medicare cards at the time of service.

Update the patient registration information with the MBI number as soon as patients present with their new card.  It is best to scan the new Medicare card into the practice management system.  Scanning all insurance cards is a good practice since it allows the billing team to easily access the information and correct or update, as necessary.


Now is the time to make sure that the practice management software can accept the new 11 digit alpha numeric MBI.  Whether you outsource your billing and collections or have an in-house team it is imperative to make sure they are prepared to file claims with this new number.

Your billing and collections team can also participate in notifying your Medicare patients about the new cards.  Every interaction with a Medicare beneficiary is a chance to remind them about the upcoming change and what they need to do.

As part of Onpoint Medical Solutions due diligence, the practice management software has already been tested.  The software can accept the MBI, claims are accurately populated and can be submitted.  Make sure your billing and collections team has done their due diligence, as well.


CMS has indicated there will be a transition period through 2019.  A knee jerk reaction is to think it is way too early and you will worry about that later.  However, you don’t want to wait until the last minute.  If you postpone this will become a daunting task.  Contacting all of your Medicare patients will require some time.  Failure to update and utilize the MBI will ultimately result in claim rejections and delayed payments.

Did You Renegotiate Your Payor Contracts to get the Raise You Deserve?

Is it Time to Renegotiate Your Payor Contracts?


There are too many times to count where we’ve encountered physicians who haven’t renegotiated their payor contracts for years and sometimes never.  If you fall into this category then don’t waste another minute.  Don’t miss out on getting paid more for the work you are doing.  Get those contracts out, dust them off and prepare to renegotiate.

The following steps will help you through the renegotiation process and alert you to some key terms that payors don’t want to include in your contract but you should make sure they do.

Contract Review

  1. Study your current contracts and fee schedules
  2. Review contract terms
  3. Know your term and termination language and notification requirements

Do Your Homework

  1. Generate a list of DX codes with frequency for the quarter and the year
    1. This will show you what codes you use;
    2. 20% of the codes are used in 80% of the cases and those are the ones you want to have the higher fees
  2. Know your highest volume CPT
  3. Benchmark reimbursements against the Medicare fee schedule
  4. Prepare and excel spreadsheet listing the top reimbursement and the top highest carrier.
  5. Know your practice model
    1. What makes your practice unique?
    2. Do you have an in-house lab, are you bilingual, do you provide consultations, are you double or triple boarded?  Are there demographic advantages?  Do you provide ancillary services?  These things could get you higher reimbursements.
  6. Make sure you are on ACH for all carriers.  Your billing service should do this for you.

Know what you Expect/Require from the Payor

  1. Do not allow the carrier to just look at your taxonomy number because they might not understand or see the whole picture.
  2. Require the carrier to review your prior utilization
  3. Address the top 25 used ICD-10 codes that you identified when you did your homework
  4. Determine carve-in and carve-out ICD-10 codes.

Key Terms

  1. If you have an evergreen contract (one that renews automatically) then you should have a set percent increase every year.  If it isn’t an evergreen contract you have the right to renegotiate every year.
  2. Claim adjudication should be daily not weekly and make sure this is spelled out.
  3. When they ask for records, make sure the contract spells out the turn-around-time for their review.  It should be 14 days.
  4. The contract should spell out the denials management process, i.e. TAT, appeals.
  5. How are refunds handled?  Take backs should be written out of the contract.
  6. Check and comply with their CAQH and professional liability update requirements.  You must stay updated or the can kick you out for non-compliance.
  7. Understand the language of the contract.

The Proposal

  1. Prepare an impactful proposal letter.  This is a sales pitch.  Most physicians don’t like to think of it as a sales pitch but that is what it is.  Sell yourself and your practice.
  2. Don’t mention pricing at this point
  3. Send your proposal to a specific person, i.e. your network representative.
  4. Track it.  The payor will take approximately 4 weeks to internally evaluate your proposal and do their utilization review.
  5. Follow up.  Call every 15 days.  Don’t be surprised if you get the run-around.  Just hang in there, call and remind them that you have called before and that you are checking on the status.

The Offer

  1. Do not accept the first round of negotiations.  Always counter
  2. Evaluate, compare and decide on next steps.
  3. There will likely be things you like and don’t like but decide what is most important to you and be prepared to compromise.  Both sides should win and lose something.
  4. Is the rate increase retroactive?  If so, to what date?


  1. Before you sign, verify that the contract includes the reimbursement rates, the increases, and all terms.
  2. Sign the contract and return it certified mail.
  3. Tell your billing company.  Your hard work will only pay off if you have good revenue cycle management.  The billing company needs to know
    1. the new fee schedule;
    2. claim adjudication terms;
    3. denial management terms;
    4. turn-around times; and
    5. refund management terms
  4. Track your reimbursements
    1. Check EOBs for the first few months and periodically thereafter to make sure reimbursements are consistent with the new rates.  If you have been underpaid you can rebill for the difference.

Renegotiating payor contracts is time-consuming and can be frustrating but it is so necessary.  You already know that insurance companies aren’t going to look out for you.  You must look out for you so start today and take it one step at a time until you get your raise.


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