Let’s assume you are working for a large physician practice or medical group and you are the coding manager. You check your staff’s work against the providers’ documentation, and everything seems to be in order. Insurance claims should pay without delay and you smile to yourself and think, “Life is good.”
And then it happens. The doctors call an urgent meeting with the office manager, the billing manager and you because net collections are decreasing and they are not sure whose fault it is.
How do you even begin to compile data to ensure it is not the coding department’s fault?
Physician Practice Management: Causes of Declining Collections
There are a number of reasons why net collections can decrease. Physician practice managers should first review the billing and collections process and monitor the turnaround time from when the provider locks his medical record, to when the coder gives the biller the claim to enter and transmit. Look for any claim denial trends and be diligent about reading electronic mail from both the clearinghouse and the insurance payer. Not all claim denials come to you on paper. Many deny at the electronic level and must be corrected online and retransmitted.
Make note of any changes in payer mix and review your contracts with payers. Coders should audit every provider’s charges and make recommendations to improve documentation and coding. Even though your staff is coding accurately against the provider’s notes, a few simple words from the provider such as, “spent 50% of this visit providing counseling and coordination of care” or “during this preventive visit I found the patient to have a 102 degree temperature and a 1.2 cm laceration of the arm which appears to be infected. I took a culture of the wound and cleaned out the wound” can alter the way a coder codes the visit. Often times a patient makes an appointment for an annual exam and the provider uses “well visit” as the reason for the visit, when, in fact, both a preventive and E/M visit can be billed together.
Additional indicators to look for:
• Charges, payments, and adjustments by provider by location
• Average charge and payment per patient visit
• Number of referrals by source (newspaper, hospital directory, patient, provider)
• Physician cancellation rate
• Patient cancellation/no show rate (Look at doctors who have a large Medicaid patient base and schedule back-to-back appointments for family members and do not show up, wasting a large block of time that could have been used by another patient) This is very common practice.
• Number of new patient per full time employed provider
• Number of patient encounters per ancillary provider
• Billing staff turnover ratio
• Billing staff productivity
• Accurate reconciliation of charge capture documents to appointment logs, inpatient logs, nursing home logs, etc.
• Average number of missing encounters
• Time of service collection rate (Very important since co-payments often are more than insurance reimbursement)
• Appointment availability
• Patient wait times at time of service
• Internal control of cash and checks received through the mail, as well as receipts paid at time of service, over the counter collections on accounts from patients and monies received by credit card)
There are many reasons for decreased revenue, but improved documentation translated into reimbursable codes, lessening the lag time between visit and claim submissions, matching all visits to daily charge slips, analyzing denial trends, and balancing out all money collected would be the first steps I would recommend when asked for a financial analysis of the practice.