Margins have been shrinking for several years in medical practices. Commercial insurance companies continue to tighten their purse strings denying or pending claims. MIPS has made for mounds of extra work to receive reimbursement that barely keeps up with inflation. A fewer number of practices were penalized under MIPS and therefore incentive payments ended up much lower than expected. How can your practice increase your revenue through these changing payment methodologies? Five key areas are listed below – check to see if these strategies fit into your practice.
#5 – Chronic Care Management & Annual Wellness Visits
Did you know the average Medicare reimbursement for CCM is approximately $42/patient/month (about $500 per year per patient)? These are 20 minute non-face-to-face services for patients with two or more chronic conditions. There are companies that will provide CCM services for a percentage of the reimbursement to ensure your practice meets all the requirements. The AAFP details the various components for Simple and Complex CCM.
Annual Wellness visits are 100% covered for Medicare beneficiaries. This is an opportunity to connect with your patients once a year to update their health risk assessment, review and update their medical history and talk through the patient’s care plan. Additional revenue for the AWV is an added benefit to your practice. Review the requirements for AWV from the AAFP.
Solution: Develop a strategic plan surrounding medicare beneficiaries for AWV and CCM evaluating costs of implementing these services internally and/or outsourcing part of these services. For CCM consider a pilot program with a small group of patients to streamline the process.
#4 – Payer Contract Issues
Reimbursement rates are already struggle. You want to make sure payers are not short-paying you what you are owed. If you don’t track your allowable rates and compare to what you are being paid – you will not be able to respond to this loss revenue.
Solution: Load allowable payer reimbursement into your practice management software. Review variance reports monthly to identify missing revenue.
#3 – Credentialing Issues
Do you cringe when you hear the word credentialing? Have you been in a situation when your claims have been paying correctly and then suddenly EOBs start coming in and saying you are out of network? What happened – did you miss a notification for a re-credential application or did the payer make an error in their system? Claims for these scenarios may not deny but they may fall to an out-of-network deductible causing your patients significant out-of-pocket expense.
Solution: Outsource Credentialing Management to professionals who know the forms, the on-line processes, and who have contacts to get you answers timely avoiding or reducing any lost revenue.
#2 – Mediocre Patient Balance Management
Did you know that patient balances have increase over 11% for physicians and nearly 88% for facilities? Patient responsibility will continue to increase year-over-year as deductibles climb and provider networks become narrower.
Solution: Verify benefits prior to patient services collecting co-pay, co-insurance, or a portion of the deductible prior to to seeing the patient. Develop a consistent patient statement process – incorporating electronic communication (email and texting). Allow payment options for patients who have higher balances.
#1 – Insufficient Denial Management
Payers today are finding all the reasons not to pay claims. UnitedHealthcare was forced paid $305 million as a result of a lawsuit that was settled in 2009 in regards to a flaw in UHC’s internal software used to calculate reimbursement for out of network payments. A settlement for $11.5 million was reached in 2015 again UHC in regards to systematically denying physician claims. A new lawsuit in 2019 has been filed against UHC based on denied, delayed or short-paid claims. Has your billing office been able to keep up with the denials, $0 payments, or short-paid claims? Timely follow-up on these items is critical to maintaining cash flow in a practice.
Solution: Evaluate the structure of your billing department or services. The majority of time of the billing process should be spent on denial management. The remainder of the revenue cycle should be fairly automated and require less attention. Outsourcing denial management or the entire revenue cycle is also a potential opportunity of cost savings and increased revenue. (Check out PractiSynergy for Medical Billing outsourced needs).