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No red flags: filing neat, complete, and accurate insurance claims

January 28, 2020

Through customer-focused service, open communication regarding office policies, immediate insurance verification, and daily cash flow monitoring, you can significantly increase the efficiency of your front office.

After you’ve taken these initial steps, you are now ready to accomplish the next critical task: filing claims completed in accordance with the guidelines of insurance companies and the federal government.

Because full reimbursements from insurance carriers oftentimes aren’t calculated until after the claim has been filed (which creates a certain level of uncertainty), private practices struggle to turn a profit. A couple of other factors also contribute to the financial struggles of the average private practice:

1. Medicare: Typically, a doctor is reimbursed less than $30 for a Medicare patient despite the fact that he or she will often require more attention and time than a covered patient. Whether it’s taking vitals, administering specialized testing, or answering the increased number of questions that are common for elderly patients, the time-profit ratio for Medicare patients is very low. Depending on the degree to which the practice accepts Medicare patients, this marginal reimbursement can do real damage to a practice’s bottom line.

2. Private Insurance Carriers: While the average reimbursement amount for the covered patient is nearly twice what it is for the Medicare patient, covered patients don’t visit the traditional doctor’s office nearly as often as their Medicare counterparts do. And when they do see the doctor, it’s typically for minor health issues that require basic examinations resulting in a lower overall reimbursement amount.

But don’t lose heart. There are meaningful steps you can take to increase your time-profit ratio, which means healthier reimbursements and a steadier cash flow.

1. Add Testing to the Traditional Doctor’s Exam. Today, lab tests, EKGs, and other basic tests are being performed in-house more often, which increases the revenue for a private practice. The reimbursement rate paid on these tests will more than cover the cost of administering them, allowing the practice to make up a portion of the lost revenue from the patient’s basic exam. In fact, insurance carriers often encourage in-house testing because it’s more cost efficient than issuing the tests to be administered at an acute care facility.

2. Submit a Clean Claim. In order to receive full reimbursement from an insurance carrier, the physician must submit a clean claim that accurately documents the exam and includes any necessary tests that were administered. Physician documentation is critical, as insurance carriers often perform audits. If discrepancies are discovered between claims and documentations, the carrier will withdraw previous reimbursements. Therefore, be careful that you don’t administer frivolous testing simply to build your revenue. Just as insurance carriers look for discrepancies, they also notice when a private practice routinely administers tests that come back negative. Avoid raising any red flags by keeping your claims neat, complete, and accurate.

Despite the overall decrease in carrier reimbursements for basic physician visits, there are significant steps you can take to stay profitable and thrive even in the most uncertain economic environment. By efficiently filing a clean claim that is supported with accurate clinical documentation, you are guaranteed to receive timely and potentially higher reimbursements.

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