Medical Practice Management — Physician Reimbursement

Achieving financial success within a medical practice involves specific areas of concentration beginning with focus on front desk procedures as well as the employee’s role in customer service. In medical practice management, competency in obtaining and understanding the various health insurance plans is vital to a practice since correct information is what ultimately brings the revenue into the office. Along with having a basic understanding of coding and billing, the front desk’s goal is to optimize the physician’s time with concentration on quality assurance.

Medical Practice Management- Physician Reimbursement

Every coder knows that accurate documentation must support medical services that are provided to each patient that is treated. Although the physician is primarily responsible for recording medical information, ancillary providers must also understand basic medical coding and billing in order to properly document additional services such as injections, venipuncture, etc. It is the uncaptured services that cost practices thousands of dollars in lost revenue so it is imperative that quality measures are ongoing to ensure all fees are billed out.

Coders and billers should be properly trained to promote a healthy revenue cycle. Physician Practice Managers (PPM) must work to keep the lines of communication open between all departments in order to maintain steady cash flow; they also must be able to explain delays in payments that involve clerical, clearinghouse, payer, and coding errors. Studying denial trends and configuring the aged accounts receivable are but a few tasks in the job description of the PPM.

What are some of the key components all personnel must know to maintain financial success?

  • Payer contract guidelines
  • Federal and state requirements
  • HIPAA approved code sets that include ICD-9-CM diagnosis codes, CPT procedure codes, and HCPCS Level II service and supplies.
  • Understanding what is required when submitting a clean claim:
  • Reason for the visit (Chief Complaint)
  • Relevant history
  • Physical exam findings
  • Prior diagnostic test results
  • Assessments of patient’s condition
  • Clinical impression or diagnosis
  • Medical plan of care
  • Date and eligible identity of the observer

In CCO’s PPM course, you will find detailed information outlining the guidelines required for each part of the patient’s documented visit. This is very important because based on the documented medical necessity, review of systems, exam, and medical decision making; coders and healthcare providers will choose a level of service that is appropriate.

In addition to the level of service provided, the location where the services were rendered must be correct. Each place of service (POS) has an assigned number which correlates with a location.

For example, the number eleven (11) represents an office location. Assigning the wrong POS to a visit is not an area to be careless in.

Reimbursements are based on Relative Value Units, which means the provider gets paid for his work, his practice’s expenses, and his malpractice insurance. If he performs a sigmoidoscopy in his office, he will get paid more money due to his overhead expenses. His reimbursement will decrease if he does the exact same procedure in a hospital outpatient setting because the hospital will collect that portion for the overhead expense.

Physician practice managers wear many hats in a medical practice. They need to be on par with the billing and coding departments and be able to recognize denial trends, understand when an ABN should be presented to a patient, and they must know the steps to appeal a claim along with the insurance payer’s specific requirements. For example, one payer may allow you to correct a denied claim online with an immediate response accepting the claim for payment; another payer might want you to print out a corrected claim, fill out a universal appeal form and send a copy of the explanation of benefit (EOB) with the denied patient visit circled in black marker via the U.S. Postal Service. It’s a lot to remember, but certified PPMs will not have a problem guiding their staff.

Providers must be credentialed, re-credentialed, and re-validated with a variety of payers continuously which is a time-consuming job that can never be ignored. Current physician information and copies of current medical licenses, DEA numbers, and malpractice insurance, to name a few, must be maintained with each payer. If this task is overlooked, healthcare providers will not get reimbursed for their services. An employee may be assigned the job of managing this crucial information, but the PPM must stay on top of it at all times. In addition to this, PPMs usually work with the physician and insurance carriers on negotiating of contracts. Learning the formula to calculate the total money collected for all services by patient visits allows the practice leverage when discussing reimbursement rates.

There is so much knowledge a PPM must possess to be indispensable. Basic information on private health care as well as knowing how Medicare would qualify as a secondary payer are important areas of focus. Knowing that health insurance is available for children who do not qualify for Medicaid not only assists a patient but gets the practice reimbursed as well.

Qualified physician practice managers are challenging to find. Ask any private or group practice about their search for a knowledgeable PPM. Talk with a medical coder or biller about the problems they encounter due to poor office management and minimal feedback. Discuss cash flow concerns with doctors who cannot meet their payroll.

More than ever, certified PPMs are needed to manage the business of medicine and reimbursement. Salaries are competitive and you can be guaranteed, this management position will never leave you bored and looking for something to do.

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