A s a healthcare consultant specializing in multi-specialty practices, I am aware of the basic chiropractic mentality. How do I make more money? What can I bill for now? The key in today's world of compliance and regulation is to bill more effectively; to get paid for what you bill, not necessarily bill more. New rulings by the Office of the Inspector General (OIG) put great emphasis on billing properly. To bill more effectively, you must first understand how to bill and collect properly. I continually work with my clients to improve their billing protocols. I often used to wonder why one of my doctors would have a M1LLION-DOLLAR-A-YEAR PRACTICE, and another doctor, just as talented, not. The key is fundamentals. Vince Lombardi understood the importance of fundamentals; the importance of Practice, Preparation and Perseverance. When it comes to collecting, the three P's are germane. Following arc my 7 Habits of Highly Effective Collections. 1. Customize your strategy for handling denials Track them, set up your system and follow up quickly. Appealing denied claims costs both money and valuable staff time. Tackle that task—with a plan aimed at getting the best return on both your dollars and your efforts. That planning begins with measuring and understanding your practice's denials. Explanation of Benefit (EOB) forms must be answered daily. Despite its relative simplicity, a surprisingly large number of practices don't even track denial data. Denials hold the key to reimbursement. Billing and collecting are two separate processes. Billing is easy; any computer can bill. But only people can collect. Know which insurance companies pay for what. Keep a log of each company. 2. Track a week Practices with sophisticated computer systems can pull denials from their databases. Make sure your manager and billing staff is properly trained to utilize your equipment's capabilities. If you don't have such a sophisticated system, you still can develop useful denial data with a computer spreadsheet, or even a pencil and paper. Track a week's worth of rejected claims and record each rea- son for denial from the EOB forms. By the end of that week, you'll probably have exposed any weaknesses in your practice's billing process. By addressing those problems—• whether they lie in gathering patient data, verifying eligibility, confirming referrals, improper coding, or in needing to send notes and reports— you'll send cleaner claims into the system and, ultimately, reduce denials. Start with your major payers, because doing so provides a snapshot of what's happening in your practice. Most denial problems stem from procedures within your prac- tice; correcting them helps across the board. By initially working with just one payer's claims, your billing person will initially examine only one type of EOB form, making it a far smoother operation. While twenty-or-so basic problems generate most denials, different payers' EOB's express common reasons for their denials. All payers have patterns. Learning their patterns for denials will help your staff understand how you must bill specifically for each company, according to its rules and regulations. After you master one company, go on to the next. You can apply the same process to different insurers later. 3. Getting attention Analysis of the denials of the practice's primary doctor, illustrating how much profit leaks out of the reimbursement process—and the doctor's pocket—just might make managing denials a higher priority. Giving denials their proper attention often requires adding staff; that's more likely to happen when everyone realizes how much money you're leaving on the table. What this means is it is often not how much you arc making, but how much you are losing. Once you've started tracking and understanding patterns in your denials, set up a systematic approach for handling them. We recommend grouping them by the reason for denial. Think about what you must do to re-work the claim. Then move the claim to the person most capable of fixing it. If you have a tall stack of coding denials, have your best coder carefully review them. If you identify coding problems specific to one doctor, asking the insurance company for its input teaches the doctor, which can only make everyone's life easier. 4. Build a process Separate the denials requiring only basic record-pulls for information needed to complete the claim. Give those claims to one person who can efficiently handle the file work. Efficiency matters, due to the surprising cost of appealing claims. Various estimates suggest that it costs about $10- to-$25 to rework a claim. That amount's significance varies by the procedure-mix and number of claims your practice generates. In many chiropractic and medical specialty practices with higher-priced procedures, individual claims represent higher dollar amounts, and the value of following up on denials is obvious. In chiropractic and primary care practices heavy with office visits, the appeal can eat up a big chunk of the reimbursement time. Time is an important part of collection. Often, clinics have one employee to answer phones, book appointments, etc. A collector should spend 100% of his/ her efforts on collection. It is doubly important to analyze— and. ultimately, reduce—your denial rate. Some smaller offices that cannot afford more than one full time staff member should consider utilizing the services of a billing company. I have worked with many excellent companies. They usually charge in the range of 6-to-8% of only what is collected. Often, this can be less expensive than a full time employee. 5. New strategy Although estimates suggest that about 60% of re-submitted claims are paid, we believe the traditional process of re-submit- ting denied claims is slowly losing its effectiveness, because of computers. Back when people made more payment decisions, a different rep reviewing the appealed claim frequently paid it. Today, however, claims reps' computers more likely reject a claim the second time, because the software interprets data the same way it did before. The key is to try to find someone in the company that you can develop a working relationship with. Then you should send your re-submits directly to this person. In my office, my employee, Iris, had people she could work with at every insurance company. She knew them and their families by name. She was an effective collector. Billing managers must be sharp and confirm that their postings are up-to-date before re-submitting. An insurer could mistakenly view your appeal as intentional duplicate billing— creating an expensive, time-consuming mess to untangle. 6. Don't quit easily Scrupulously analyzing billing procedures and submitting pristine claims won't eliminate denials. A recent article by a national billing company reported a 13.6% denial rate among its members, and a 7% denial rate among its so-called "better performing" practices. Everyone gets denials: the key here is to learn from them. Often denials are processed simply because the insurance company's computer does not recognize a portion of your claim. At some point, it makes sense to write off certain denials and move on; but follow your plan and exhaust its options before you walk away. There's no magic formula for making that decision; consider the charge amount and volume of the claims. along with the payer's importance (currently, and in the future) to your practice. If the insurance company does not pay, remember the patient is liable. Bill the patient. Have the patient call the insurance company. Often their complaining is far more effective then yours. Let the patient be a part of the collection process. Remember, further, you are doing them a service. The traditional payment weapons— calls, letters, meetings, attorneys' letters, letters to the state insurance commissioner, arbitration and lawsuits—have their place. Again, focus on your major payers. What gets claims through their systems? Where and how do they get stuck? What tactics have worked in solving past problems? Different payers react differently. One approach doesn't fit all. 7. Hesitate...and lose Commonly, there is one mistake in handling denials: Waiting too long to take the steps beyond calling and re-submit- ting denied claims. A few weeks after re-submitting, follow up aggressively from your end. Remember, there is a time limit with denials... you're on the clock. That makes gathering and keeping organized denial data vital to effective denial management. If you establish a system and keep after it, you'll stem that flow of cash from your practice. This Is a first in a series of articles by Dr. Kaplan to be featured In The American Chiropractor. Dr. Kaplan is the CEO of MBA, Inc., one of the nations largest multi-specialty consulting companies. Dr. Kaplan ran and operated Jive of his own clinics, seeing over 1000 patient visits per week. He is the best-selling author of Dr. Kaplan's Lifestyles of The Fit and Famous, endorsed by Donald Trump. Norman Vincent Peale and Mark Victor Hansen. He was a recent commencement speaker at New York Chiropractic College and regularly speaks throughout the country. For more information about Dr. Kaplan or MBA. call 561-626-4110.
