Welcome to the second edition of our quarterly newsletter. We hope you found our first issue interesting, informative and enjoyable. In this edition, we have a column called “Meet Your Biller.” This is an opportunity for us to highlight one of our billing staff so that you get a richer sense of who we are. We’re proud of our people and the job they do on behalf of you, our clients.
In our next edition, we’ll be including a section we’re calling Client Spotlight. In addition to the invaluable care you provide your patients in the day in day out work of private practice medicine, many of you also do inspiring pro-bono and charity work that we feel compelled to shine a light on. So, with that in mind, starting next quarter, we’ll feature one client practice each issue that is doing work that really expresses for us a generosity of spirit.
Curt Hill, CEO
By Ron Rosenberg
The business process that creates income for clinical services has many steps. When some of them are performed sub-optimally, they will still produce 80% – 90% of the expected income. However, there are other steps that will reduce income significantly — more than 10% – 20% — if they’re not carried out with precision.
One of those critical steps is identifying a clinical service as a charge, which ultimately results in translating that clinical service into income. While this may seem like an obvious and easy-to-accomplish task, clinical services that are provided and not captured as charges represent one of the largest sources of lost income for medical practices. A provided clinical service that is not captured as a charge is a free clinical service.
For many practices, especially those that provide services outside of the office, income can be lost if the clinical service is not captured as a legitimate charge.
The key to achieving complete charge-capture is having the proper tools and systems in place to capture all services as charges. This ensures that those captured charges are successfully transferred into the billing software. Monitoring the charges and comparing them to other data then ensures complete capture.
The components required for complete and accurate charge-capture include charge-tickets/slips that are easy to use and easy to track. Alternatively, using an electronic medical record (EMR) system allows the physician to enter charges in the medical record that are then transferred into the billing system. Some practices use both a charge slip and the EMR. Another infrequently used (and inferior) system is abstracting charges from the medical record.
Another option is an office charge-capture system that is useful in some environments and replaces the charge-ticket/superbill with a schedule list for each physician. As a patient is seen, the CPT and ICD-9 codes are placed on the list. At the end of the day, charges are entered from the list.
Click here to read more about charge capture options
Ultimately, the one who provides the clinical service is responsible. While there may be both staff and electronic tools to assist in charge-capture, the physician is ultimately responsible, since the physician’s income, — directly or indirectly — is a function of billed and collected charges.
The expanded acceptance and implementation of EMR systems has in some ways made charge-capture easier, and in other ways presented new challenges. The challenges include:
- Who enters the charge into the EMR, the physician or a technician?
- Who finalizes encounters, and when does it happen? This important step includes reviewing the encounter and assuring that all services are captured as charges.
- Is there a process for assuring that testing ordered during the exam is captured in the EMR?
- For EMR software that is not integrated with the billing software (one database, no intermediate software connecting the two) but rather is connected by a third software package, is there a step in your process to assure that every charge is successfully transferred from the EMR to the billing system?
Monitoring charge-capture effectiveness
Whether your practice uses a charge-ticket/superbill or EMR, a process for auditing charges to assure that all services are captured must be in place. There must be systems to verify charge capture, both in and out of the office. The patient list and/or missing ticket reports from the computer system are useful in the office, and comparisons between charge volumes and O.R. logs and/or surgery schedules are useful for services provided outside the office.
The primary key to capturing scheduled services outside the office is to assure that all scheduled services are in the practice’s scheduling software. A commonly used adjunct system for capturing surgical services is for the office staff to provide the Ophthalmologist with a surgery list, including the patient’s name and the scheduled procedure. The surgeon checks off the patient after each procedure and adds or deletes any procedures if the surgery is not done exactly as scheduled.
Another way to capture non-office charges is to generate a charge slip when a surgical case is scheduled. This slip is given to the physician to return to the billing staff after the procedure has been completed. However, these processes, coupled with depending on physician reporting, increase the likelihood for missed non-office charges. Further, there is no way to audit the charges to identify those that have been missed if they are not formally scheduled in the practice’s billing software.
The major challenge is for unscheduled services outside the office, for example in the Emergency Department (ER). It is up to the physician to list the services provided, along with providing the patient’s demographic and insurance information, often on a hospital face-sheet. For ER and emergency surgery services, it may be beneficial to generate a report from the hospital that lists each patient seen by the practice’s physician to compare to captured charges.
The major pitfalls include:
- Delays in completing encounters. When a physician does not complete their encounters before leaving the exam lane, the chances for missing a service on the charge slip or the EMR increase. That delay also makes auditing missing charges much more difficult.
- Not reviewing each encounter (generally done by the physician and technician) to assure that each service (especially testing) is captured on the charge-slip or in the EMR.
- Not entering work-in patients into the schedule, defeating the automated auditing process (missing-ticket report).
- Not assuring that each charge entered into the EMR is successfully transferred into the billing system.
- Not effectively auditing charge-slips to assure that each one makes it to charge-entry.
- Not using a proven process to ensure that services provided outside the office (hospital, ASC, emergency room, nursing home) are captured completely.
- Not being fully trained on bundled or allowable services, leading to the physician and/or staff not recognizing when a service is separately billable.
There are a few critical steps in the business process that, when sub-optimally executed, will significantly reduce the practice’s income. Charge-capture is one of those steps. It will serve the practice well to review each component of the charge-capture process in order to assure that every clinical service is captured as a charge.
By Paula Muhlenbruch
Partnering with insurance carriers is necessary for all medical offices/physicians if you want to be paid by them. In order to partner with both commercial and government carriers you must be vetted as a viable resource by completing each carrier’s lengthy credentialing process.
The consequences of not obtaining timely and/or accurate credentialing is lost revenue. Insurance carriers will not reimburse medical offices/physicians that bill for services provided by professionals that have not been properly credentialed.
Credentialing is not a difficult process but does need to be done by someone who is able to pay attention to details and respond to insurance companies’ requests within specific timeframes. It is important to start the credentialing process as soon as possible since it can take up to six months to get approved.
Not credentialing a provider in a timely manner could cost your medical office thousands of dollars that can never be collected from the insurance payer or the insured.
If you have any questions or would like more information on credentialing please feel free to contact me at firstname.lastname@example.org.
Meet the Biller: Megan Maxwell
Megan Maxwell joined the PRMG team in September 2012. She is a graduate of Sanford Brown College’s Medical Billing and Coding program and is a Certified Professional Coder through AAPC. Megan is currently pursuing her Certified Ophthalmology Coder Credential through the AAPC as well. Prior to joining to PMRG, she worked at a private practice and at an ambulance company.
Megan handles a number of our accounts and manages a team that works with clients on a variety of practice management platforms, including Advancedmd, Nextgen, Nextech and EPIC. She enjoys problem solving on accounts, learning new systems and getting the impossible claims paid.
Megan and her husband Brian enjoy spending time with their sons DJ and Josh and their two dogs, Dancer and MooMoo. She is a soccer mom and coach for her son’s team. Megan enjoys outdoor activities such as fishing, swimming and hiking. Megan and her family are avid Nascar and short track race fans.
Megan’s clients will attest to her high level attention to detail (some call it OCD). We are lucky to have Megan on the PMRG team!