We recently interviewed Eryca Gonzalez owner of Clean Claims Revenue Cycle Management who for the last ten years has been persistently serving physicians in medical billing, having worked all phases of the revenue cycle. We asked Eryca to give us some insight into the struggles physician go through today to keep up with constantly changing payer rules and tightening reimbursements.
Here is Eryca’s story: Prior to opening Clean Claims, I was given the opportunity to open and manage a medical billing company that is still in business today and highly successful. I started on the front lines and persistently climbed up through self-teaching and through the invaluable insights gained from the doctors I served. Serving physicians billing needs in my own company was my long term goal, but I here was able to experience the trial and errors that a new business faces.
My goal was to offer provider driven standards and a proven track record of success in the medical billing field. I formed a team that today, ten years later, specializes in claim submission, credentialing, reporting/analytics, practice financial assessment, and medical staffing solutions. We take pride in locating the problems interfering with the Revenue Cycle and provide permanent solutions to fix them.
The difference at Clean Claims is that we take an active role in each practice we serve. We form a relationship and partner with each practice in an effort to better serve their patients. By working alongside the practice’s support staff, we’re able to assist in implementing new processes and workflows that complement their unique revenue cycle. We consider ourselves an extension of your office.
Claim submission and billing as a whole, can be intimidating to a small practice and a burden on administrative staff. As we know, insurance requirements whether commercial or government are constantly changing. Medicare can change requirements on a quarterly basis so maintaining current up to date billing knowledge is a task in itself.
Outsourcing to a trusted partner that maintains high skill levels can be a cost effective option considering you’ll have a team of seasoned billing staff working on your claims, denials and customer service; without incurring the expenses of annual salary/benefits, payroll taxes, WC insurance, office supplies, furniture, billing software licenses, etc. It can also get rather costly to maintain the amount of continuing education to your billing staff requires, which is often an overlooked expense.
It’s unfortunate, but what happens if a biller leaves the practice? When missing a key player for any amount of time, claims aren’t submitted and rejections aren’t addressed. By engaging a team of billing experts, your practice experiences a continuous flow of clean claims going out the door creating a stable revenue cycle.
Some providers may shy away from outsourced billing due to a sense of losing financial control and that fear is understandable because most big boxed billing companies offer claim support only. They standardized their medical billing processes in an effort to maximize their own revenue. After the onboarding phase, the warm, fuzzy feelings subside because there is no real partnership. By continually involving you and your team in your billing process, we make the patient experience better. Time must be invested in reviewing multiple medical billing services as this is not a one size fits all industry. In the end you want the one who will do the work right while providing the highest possible care to your patients.
Doctor’s may not realize it, but office administrators and billing managers do, that finalizing visit/procedure notes in a timely manner is an absolute necessity. I have lost count of the amount of times that I have had to chase down a physician to finalize a chart that was going to run in to timely filing. No one wants to inflict additional stress on a doctor’s busy schedule, but the longer it takes a physician to finalize charges, the more time consuming it becomes to collect payment for those visits. Finishing up your charts goes a long way to getting paid in a timely manner.
When claim submission isn’t normalized and insurance payments aren’t consistent, your management team will struggle to forecast revenue.
Every position in a medical practice contributes toward the revenue cycle and all good billers know that the revenue cycle starts at the front line. We partner with your front office to eliminate the denials. By preparing your front office to avoid delayed payments your revenue cycle levels out and the payments are deposited like clockwork. Each department serves a purpose and if their tasks are done correctly, the combination of efforts results in clean claim submission and the overall stability of your revenue cycle.
After the physician drops the charges, the next challenge surrounds the front desk denials/rejections. Most practices will appoint an office manager that will oversee the front office team and provide guidance as necessary. More often than not, your practice manager will be overworked and may not address continuing education until they hear a biller griping about multiple claim denials. Please carve out time on a monthly basis to keep your front office team up to date on any changes that affect their responsibilities and your patients. IF your front office staff is fully trained and knowledgeable about insurance, they will have completed the following:
- Patient demographics verified and entered accurately
- Insurance information collected, entered and scanned in the patient’s chart
- Skilled Nursing patients, contact the nursing facility to inquire about consolidated billing. Document a billing contact and phone number.
- Insurance eligibility/referrals/authorizations documented, authorization number entered in the proper field which populates on the patient claim form.
- Copay collected upon arrival of visit. If the patient has a deductible, load plan specific fee schedule which creates an estimate of the allowed fee by cpt.
If any of the above pieces of information are missing, either your claims will be scrubbed by your practice management software and denied submission, occasionally a payer denial or they will become front end claim rejections from your clearinghouse that will need to be reworked. The most frequent rejections are:
- Patient name or insurance ID invalid. Never add nicknames, the name needs to be entered as it appears on the patient drivers license and insurance card.
- Verify that you have chosen the correct insurance carrier and that the carrier has an EDI number assigned to it. If the wrong plan is chosen, the claim will be submitted to the payer and returned as needing to be submitted to the local/regional plan.
- Date of birth is frequently an issue as well. Always review your demographic entry with the patient prior to scheduling their first appointment.
- Patient policy not in effect on the date of service. Most software has integrated eligibility options available but may not give you the big picture regarding the coverage. It is a better financial decision to have a team member checking the specific plan coverage, than to have denied claims that will potentially never be paid.
- Missing authorization on this date of service. When calling a carrier to authorize future services, documentation is everything. Who did you speak to? What time did you call? What telephone number did you use? Did you specify which cpt was being billed? If you received an approval for a particular service and the physician billed a different procedure code, contact the carrier and update the cpt by providing information about the visit that warranted the change. If this step is missed, the denied claims becomes non-payable and make an appeal nearly impossible.
Upon posting insurance payments and transferring the balance to patient responsibility, I run into my last obstacle. We frequently speak with patients that have received a statement and call the billing office, upset because they spoke with their physician and were told that we would not be billing for a service or that it would be “taken care of”. At times it makes sense to offer a financial hardship discount to your long standing patients but please keep your billing team in the loop with any promises that you have made so that we may fulfill the obligation.
Many physicians get trapped in a room with a patient that wants to speak about their balance. Please, don’t be afraid to instruct your patients to talk to the billing department. Your position exists to provide medical care and education to your patients. When you don’t allow billing to handle the discrepancies, you remove our credibility with the patients. Have confidence in your billing team that they will be empathetic, friendly, firm but fair.
Clean Claims is interested in collaborating with innovative, hard working specialty physicians and groups that lead a patient focused staff. Our approach is a little outside of the box in comparison to most traditional third party billing companies, come and experience the Clean Claims difference.
We can’t wait to welcome you to the Clean Claims Family!
Last Updated on February 28, 2018