Physician Reimbursement and the Physician Practice Manager

Many people ask why the Physician Practice Manager (PPM) course encourages an understanding of medical billing and coding and the answer is quite simple: Every business, large and small, can only succeed with a solid financial foundation. In some industries, the accounting is straightforward: you provide a service and bill the customer. However, in the medical practice, the billing is a bit more complex. True, the healthcare provider delivers patient care, but the medical bill does not get sent directly to the patient in most cases. It is submitted to a third party.

Physician Reimbursement and the Physician Practice Manager

This process may appear cut and dry but in actuality, submitting one bill to an insurance company encompasses many areas in a medical practice, all of which the PPM orchestrates. When sending a claim to an insurance carrier, the front desk must collect all pertinent patient information from date of birth, correct spelling of the patient’s name, address, insurance information and more. The insurance information must be verified before the physician sees the patient in order to collect co-payments and ensure that the practice will receive compensation for items and services delivered. Too often, the front desk does not follow through with every patient and by the time the billing office sends out a claim, the physician has already devoted his time to the treatment of the patient only to have the payer deny the claim for no referral, incorrect Primary Care Physician, or no coverage benefits at all. Payers are growing stricter and many will no longer backdate referrals which means that the patient must be billed, creating a poor business relationship between doctor and patient.

PPMs must also make sure that the services provided have all been captured and entered onto the patient encounter form. The paper system is still used by many small practices and most physicians tend to capture their services when handwriting their diagnosis codes and procedures on a form. However, many providers lack training or complete understanding of electronic medical record keeping, and although pertinent information is included in the documentation, they often overlook procedures that were furnished because they cannot manipulate the software. PPMs must confirm all services were recorded for billing purposes. Overlooking the cost of one vaccination on an encounter form could cost the practice as much as $175.00. Ignoring all rendered services can negatively impact the cash flow of a medical practice.

Financial security demonstrates a smooth flow within the infrastructure, leaving physicians, ancillary staff, billers and coders motivated to continue providing excellent service. The PPM should understand how the documentation ties into the recording of services on an encounter form as well as how claims are paid. In addition to this, a PPM should keep a log of all denied claims to pinpoint denial trends which can lead to the problem source and make the necessary adjustments.

A financially successful practice creates happy and motivated employees as well as content physicians and return patients.

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