The Revenue Cycle Used to be Simple

By Kathy (KMC) Weidner, MCS-P, CPCO, CCPC, CCCA

Editor’s Note: Kathy Weidner will be presenting at the 2023 ICS Chicagoland Convention on October 13 – 15, 2023. Click here to find out more!

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There once was a day when dealing with third-party payers through the revenue cycle was relatively simple.  Some even say, in jest, of course, that you could throw CMS1500 forms up into the air, and it would rain checks. In those days, good insurance was a $100 deductible with 80% coverage. That is 80% of your fee, not some arbitrary fee schedule. If you had bad insurance, you had a $250 deductible with 80% coverage. Nice as it is to reminisce about those days, we all agree they are long gone.

It’s Not as Easy As 1-2-3 Anymore

Today, we must work for our money in ways we never had to before. Often, it means putting forth twice as much effort for a fraction of our fees. We can no longer expect to get paid simply because we send in a bill to an insurance carrier. We are asked to prove what we do, and even then, we face obstacles to collections. Here is where being a collections ninja is essential. The ninja knows the rules of the game. The ninja also knows that the rules change, often as soon as the rules are learned. The collections ninja does not take “no” for an answer, understanding that having a system to follow up with carriers and being that squeaky wheel really pay off.

There is an easier way to ensure that reimbursement owed to your practice is properly billed and collected. The foundation of a good reimbursement system consists of three parts:  Data Gathering, Billing, and Collections. Each has an important role to play in the reimbursement system, whether from insurance or patients.

Data Gathering

Our experience and that of our clients indicate that this section is the most often missed or the most often fumbled. Data gathering is critical to the reimbursement process. Being able to confidently prepare for billing is paramount in the process. It starts with the New Patient Phone Call. Missteps here might be risky, especially with the rules changing with the Patient No-Surprises Act. Knowledge gained on this intake phone call will serve the practice throughout the patient’s experience. Next, we must Identify the Proper Case Type. Sounds easy, right? But you’d be shocked at the errors we see by simply missing this step. Then there must be a proper Insurance Verification —not just checking eligibility! And the second part of verification is comparing recommended treatment with the Payer’s Medical Review Policy. This last step is the piece that is missed the most and causes the biggest hassle on reviews and audits.

Billing

Billing is far more than pressing a button or putting a form in an envelope. Often, the biggest errors we see here are easily corrected. The four parts of this process begin with CPT/ICD Coding. If we’ve done our job in the data gathering stage, we know what CPT and ICD codes are allowed, and we know what modifiers to use. Then, we come to Charge Entry. This step is often done by the provider within the Electronic Health Record (EHR), but, sometimes, nobody is checking this, and errors are made and sent to payers. The process of Paper or Electronic Submission is straightforward, but who is checking the edits to be sure things have been submitted properly? Last, there is Patient Billing. This is whether it’s balance billing, or whether it’s just statements or payment plans. It’s a critical piece of the puzzle.

Collections

The final stages of this process are often the most important! If we just mailed bills and checks came back, that would be a wonderful thing…but it’s not. Systematic, consistent follow-up is the name of the game. But true collection processes begin with understanding Paper or Electronic Remittances. Then, the methodology used in Payment Posting sets the practice up for success with the next steps. The central hub of the collections system revolves around Reactive and Proactive Follow-Up, a process sadly lacking in most practices where collections are a problem. Then, what isn’t paid properly is pursued with Appeals and Reconciliation. Each of these steps takes training and experience to implement the system in practice.

Do you have a system to ensure that your money does not fall through the cracks? Are you willing to do what it takes to ensure you get paid every penny of what you deserve? Are you able to respond and adapt to the ever-changing landscape of third-party reimbursement? Are YOU a reimbursement system ninja?  If not, please join me at the 2023 ICS Chicagoland Convention & Expo on October 13, 2023. We will be conducting a hands-on workshop, these important steps and more. This session is appropriate for providers and team members ready to tackle the reimbursement woes of practice, once and for all. I’ll see you there!

Kathy Weidner, better known professionally as Kathy Mills Chang, is a Certified Medical Compliance Specialist (MCS-P), a Certified Professional Compliance Officer (CPCO), and a Certified Chiropractic Professional Coder. Since 1983, has been providing chiropractors with reimbursement and compliance training, advice, and tools to improve the financial performance of their practices. Nearing her benchmark of serving this profession for 40 years, Kathy leads the largest team of certified specialists under one roof in the profession, at KMC University, and is known as one of our profession’s foremost experts on Medicare and documentation. She or any of her team members can be reached at (855) TEAM KMC or info@KMCUniversity.com.