December 2001 Bulletin

Timely collections need go get’em strategy

Practices use ‘specialists’ for individual payers, follow-up early, send bills to patients

By Carolyn Rogers

Say your practice is bustling, satisfied patients are streaming in and out daily—but a close look at your aging receivables report shows that, unlike your patients, payment for services rendered is trickling in all too slowly. What to do?

While some payment delays are caused by the slow—many would say deliberately slow—internal process of insurers, practices are sometimes at fault as well. Inadequate staff, incomplete documentation, outdated systems and a lack of knowledge of the insurer’s requirements all can add up to sluggish payments.

It’s easy to understand the frustration billing staff experience when trying to interpret and keep track all of the rules, regulations and changes taking place in countless insurance plans. But checking in with orthopaedic practice administrators around the country brought to light a number of approaches that can help keep orthopaedic offices’ receivables in check.

One system that has seen much success—if the practice is large enough—is to assign one billing "specialist" to each major insurer.

"We’ve implemented this system in the last year and it’s really helped us get our hands around the bigger accounts," says Matthew Kilton, CEO of Valley Orthopedic Associates in Renton, Wash. "We’ve found that assigning all the Medicare patients to one billing specialist, all Blues patients to another specialist, and doing the same with all the big commercial payers like United and Aetna, has been very effective. The billing specialists get to know the rules, the nuances and the intricacies of those different insurance payers."

Becky Burnett, practice administrator for nine surgeons at the Center for Sports Medicine and Orthopaedics in Chattanooga, Tenn., agrees with this strategy. "A lot of practices have one employee who works for an individual surgeon, which means they are working with 10 or 12 insurance companies," she says. "We assign one person to each insurance company—the big ones like Blue Cross, Medicare, and after that Medicaid, Workers’ Comp, etc."

Tracking accounts receivable (AR) effectively is also key, many administrators agree.

"We track our AR weekly, and set staff benchmarks," Burnett says. "For example, a certain percentage of the total AR should be at 0 to 30 days. Or total days in AR should be ‘X’ and the total should not exceed a certain amount and a certain percentage. We give the billing staff weekly goals that they have to meet."

Kilton says his nine-member practice has started using reports to try to tackle big dollar claims early on.

"In the last six months, we’ve set up parameters—for example, if a patient has a balance of greater than $1,800 that is more than 60 days old—he goes into the report," Kilton says. "We capture those balances in the report and then call on each claim. So when the biller is calling Medicare, she has the list. She can ask, ‘Was the claim received? Do they have the documentation? What’s holding it up?’

"The report has been very helpful in getting these big dollar items, especially with the commercial payers. For instance, we found that in this market, the Blues require operative reports on certain procedures before they will even consider them. Now we know to submit the claim with the necessary information attached."

Their system could still use some improvement, Kilton admits. "We’re no longer just an orthopaedic surgeon’s office—we have our own MRI, physical therapy services, etc.—so we’re billing and collecting for a variety of services. One of the problems in transitioning from a traditional doctor’s office to a multiservice line is getting systems that communicate with each other. At present we don’t have a system that does all we need."

When Sharon Carlson, administrator for Liberty Orthopedic Associates in Liberty, Mo., started her position at the four-surgeon practice a year and a half ago, AR was a problem. "One of the first things we did was write a collections policy to give guidelines for handling ARs. Then I hired AR follow-up staff. Now I print out journals of the aging accounts, and the follow-up staff work any account over 40-45 days. We’re pretty current now—there’s been a big change in our office."

‘If we haven’t heard from an insurance company in 90 days, we transfer the bill to the patient," says Gary Walker, business manager for Spokane Orthopaedic & Fracture Clinic in Spokane, Wash. "This forces them to assist in collecting from their insurance company. We re-bill at least two or three times before sending it to the patient’s account."

While the systems mentioned above are vital to successful billing and collections, nothing is better than a "clean claim."

"The main goal in our billing office is to ensure, when we first send out a claim, that it is a clean claim," Burnett says. "We check for correct coding, bundling issues—all those things before a claim goes out."

Another way to increase "clean claims" is to utilize the front desk staff efficiently. The registration process is really the practice’s first line of "defense" when it comes to timely payment. Administrators interviewed agreed that front desk staff needs to ensure the following steps occur at registration:

• Confirm that demographic data are accurate;

• Verify patient’s insurance plans and eligibility; and

• If the patient is enrolled in a new plan, verify the coverage’s start and end date.

Although that may sound basic, overlooking one of these steps can lead to unnecessary problems down the road.

"When patients check in at the window, we ask for their insurance card every time they come," Carlson says. "And if they’ve been here in the last year, they have to review their demographic information and sign off on it. Otherwise we have them fill out a whole new form."

Another front desk issue Carlson had to work through was a problem with HMO referrals. "We had problems verifying required referrals," she says. "Now if we don’t have something on record, the patient is responsible to get that referral or they’re not seen."

An additional safeguard—asking for a driver’s license or state ID card—also has become a common step in the registration process.

"We’ve started taking a picture ID, a driver’s license, and making a photocopy of it," Carlson says. "While many of our patients are older, we also see pediatrics. We’ve had situations with divorced parents where one will call and say the bill is the other parent’s responsibility. That’s why we have the photo ID—to verify who brought the child into the office. We don’t get in the middle of who is responsible."

Kilton’s practice also asks for a driver’s license, but for different reasons.

"One change we’ve made recently is we take a photocopy of the patient’s drivers license and we use that to verify the information they have on their forms," Kilton says. "Plus, a driver’s license ID number always can be used if we have to go to collection to find someone. We also explain to patients that it’s important to prevent identity theft. Anyone could present an insurance card to the front desk, and we have no way of knowing who that person is."

Another common front desk responsibility is to collect the patient’s co-payment, although policies on co-pays seem to vary from practice to practice.

"We enforce the co-pay before the patient sees the doctor," Carlson says. "The patient is not seen if they don’t pay the co-payment in advance."

A more lenient co-pay policy is in place at Spokane Orthopaedic and Fracture Clinic, Walker says. "We do collect co-pays at the time of service, but we don’t display a sign. If it’s an initial patient visit, we try to tell them in advance, but we won’t refuse to see them if they don’t have it with them."

"We post our co-pay policy and collect co-pays as people are leaving the office," Burnett reports.

Kilton’s practice collects co-payments prior to providing the service. He adds that if the patient is a "cash account", or has a large balance, "we have guidelines that offer a percentage discount if they pay at the time of service, say with a credit card. So there’s a benefit to the patient for payment at the time of service."

Establishing an effective system for appeals is crucial.

"There are definite timelines to appeal, so handling correspondence promptly is a real priority," Burnett says. "You only have 30 days to appeal, so you have to make sure the billing person knows that is a top priority. And our billers work with our coder on all appeals."

Kilton’s practice handles appeals by utilizing a number of form letters they’ve created for each insurer. The billing specialists complete the form with the patient’s information and attach other necessary materials.

"If we don’t get a response, ultimately it ends up on my desk," Kilton says. "I’ll send a letter to the reconsideration department requesting that they get back to me promptly—citing the line in the contract that states they’re required to respond within a certain timeframe. But very few of those end up back at my desk—maybe one a month."

What are some of the payment obstacles these administrators continue to struggle with?

"One of our biggest problems has been getting reimbursed for a product for knee injections," Walker says. "We’ve learned to give the patient the prescription and let them deal with the insurance company ahead of time. We’ve also had problems getting reimbursed for a product, that we’ve used when the patient’s hemoglobin is too low, rather than having them donate their own blood."

Kilton’s practice finds the small, self-insured companies that use a third-party administrator among the most difficult insurers to work with. "We never really know what the rules of the individual plan are," he says. "The bigger companies—while they are monolithic in dealing with an approach to a problem—you get to know their approach and their habits. And of course, Medicare is always a problem."

Ensuring the practice is being paid according to the contract is Burnett’s biggest stumbling block. "There are so many different plans within a certain insurance company," she says. "For instance, there’s Blue Cross Select, Blue Cross Comprehensive Care, etc. And they all have different fee schedules."

"We have the usual problems," Walker says. "We send in a perfect claim, and they say they didn’t get it, or they find some little problem with it. But we have two very aggressive girls in billing, and if they’re not getting paid they yell and scream."

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