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BEYOND "BUSINESS AS USUAL": REASSESSING YOUR REVENUE CYCLE MANAGEMENT PARTNER By Melanie Wilkin This article was originally published in the May issue of Group Practice Journal. Over the past decade or so, an increasing number of physician practices have turned to clearinghouses or other EDI partners to assist with revenue cycle management (RCM). For most, this has represented a significant step forward—these vendors help streamline the billing process and remove the time-consuming burden of filing claims from internal staff members. Buoyed by the advances, however, some practices have fallen into a “business as usual” relationship with these vendors. They have become comfortable with a familiar partner and, therefore, less than vigilant about monitoring how effective their RCM process truly is. While many of these relationships are sound and continue to produce positive results, practices that neglect to periodically assess the pros and cons of their clearinghouse or EDI partner may be making a costly mistake. With new technologies and services constantly coming to market, physician groups that do not re-evaluate the performance of these partners could experience less than optimal reimbursement or a lack of access to valuable information that may help them further enhance revenue. North Fulton Family Medicine NFFM billing staff was unable to track the status of claims, and the clearinghouse was incapable of providing reports about any errors that might potentially trigger rejections or denials. This “black hole” meant NFFM had no documentation to verify that its claims had originally met timely submission requirements. When billing staff would contact payers about outstanding reimbursement, the insurer often would have no record of receipt, and the practice was unable to produce documentation that the claim had been submitted appropriately. Nor was the clearinghouse able to generate reports for NFFM to use as a tool to identify erroneous coding or billing patterns. The practice would telephone the vendor and request specific data. However, leadership had to wait weeks to receive reports that, in the end, were virtually unusable. Similarly, customer service provided by the clearinghouse was equally frustrating. Staff would be forced to wait on hold for up to 90 minutes and, even then, would not be provided with the answers they were seeking. Search for Advanced RCM System While conducting its search for the RCM system, NFFM identified four specific priorities:
Ultimately, NFFM selected an RCM system from Navicure (based in Atlanta, Georgia) and began implementation in April 2003. Because its billing staff is small, NFFM scheduled online group training, which was completed in an hour or two. The vendor provided ongoing support during implementation and assumed responsibility for many of the mundane tasks associated with the transition—like doing the upfront work of notifying payers about the transition from the group’s previous clearinghouse. Increased Revenue and Staff Productivity In addition, the practice is submitting cleaner claims than ever before, which means it receives fewer denials or rejections. An editing engine automatically scrubs claims against an up-to-date library of national, local, and payer-specific edits—including Medicare’s quarterly CCI updates—before the claim is sent to the payer. Billing staff is automatically notified of potential problems, and can immediately go online to review and correct any errors. Claims submitted one afternoon can be corrected by the following morning, which minimizes delays. For example, front-office staff may inadvertently transpose two digits in a patient’s insurance ID number, prompting a notice that states “subscriber not on file.” Instead of waiting for a payer denial, NFFM billing staff pulls up the claim online, makes the correction and resends it instantly. Likewise, NFFM is alerted to medical necessity issues, missing fourth- or fifth-digits in ICD-9 codes, or absent modifiers. If the practice sends in a claim for a physical that included a chest X-ray and EKG, for instance, billing staff is automatically notified if it neglects to append the GA modifier. Not only do cleaner claims generate revenue more quickly, NFFM has found they also increase staff productivity. Fewer claims need follow-up, so billing staff is able to spend time on other tasks, like contacting patients about outstanding co-pays and deductibles. NFFM generates about 300 claims a day, a number that can rise to 350 or 360 during busy times of the year like flu season. Because so many erroneous claims were submitted in the past, staff was unable to deal with them all. Today, however, the volume of claims needing to be reworked is manageable. In addition to using online reporting functionality to track claims and make necessary corrections, NFFM is also able to analyze trends and patterns. The practice can identify physicians or staff members who may need additional training in correct coding, for instance, as well as monitor payment patterns to spot insurers whose reimbursement for specific services is consistently lower than the contracted rate. Increased Cash Flow, Accelerated Growth Resolving its cash flow problems has allowed NFFM to grow rapidly. The group had 2 offices in Alpharetta, Georgia in 2003 when it converted to the RCM system. Billing staff consisted of 2 full-time and a part-time staff member. With 19 providers (10 physicians and 9 physician assistants), the practice now sees patients out of 4 offices. Only 1.5 FTEs were added to accommodate the growth. Ongoing Assessment In short, NFFM has realized tremendous benefits from critically analyzing the capabilities of its previous clearinghouse vendor. Because the practice clearly outlined its priorities and objectives, it was able to enter into a more productive RCM partnership—which has resulted in increased revenues and a healthier bottom line. To achieve similar results, physician groups would be well advised to conduct a comprehensive analysis of their current claims processing partner. The following four steps will help optimize the success of such an exercise: 1. Step back from current workflow processes and patterns. Conduct a “blue sky” assessment: If you were starting from scratch, what would the ideal relationship between the practice and the vendor include? Precisely what services would you want the partner to provide? By evaluating potential partners against these considerations, practices can ensure they work with vendors whose capabilities align with their priorities. In the end, this will translate into a more productive and profitable working relationship. Melanie Wilkin is an administrator with North Fulton Family Medicine.
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