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Payer Issues Result Revenue leaks in Medical Practice – Part 2

February 13, 2018

Revenue Leaks in Medical Practice.jpgIn the previous blog, we discussed how information gaps and missteps in the front and back offices may contribute to loss of revenues. This week’s blog is devoted to taking a closer look at what are probably the biggest headaches for many providers: the payers. Between variances in contractual agreements as well as changes in covered charges, tracking multiple payer obligations is at best challenging and at worst, frustrating and expensive. Here are a few suggestions to improve your payer relationships and reimbursement rates.

One practice’s payer-error experience

Payers do make mistakes, and even if these are small dollar amounts, if left undisputed can add up substantially in a short time.
Example: when a billing staffer was
reviewing some EOBs from a “large, well-known payer” and their remittance notices, she encountered an unknown remark code as well as finding that monies were being incorrectly subtracted in more than one area.

Examining the sequestration subtractions for 2017, she realized there were no CO235s for any 2017 dates of service, and had stopped appearing after December 2016. There were, however, some N699 codes, meaning “Payment adjusted on the Physician Quality Reporting System (PQRS) Incentive Program.”

Although this payer acknowledged and promised to fix the mistakes they continued to subtract from payments while they “worked to find a remedy.” While still dealing with that issue, the practice found that the same “large, well-known payer” was making subtractions from one of the newest staff members for “failing to follow 2015 PQRS guidelines.” The problem was this member’s NP hadn’t even been created until September 2016 – there was no way he could have reported anything in 2015!

The above mistakes were immediately brought to the payer’s attention but as of early January 2018 the practice is still waiting for their refund.

Providers who never pay attention to EOBs, with no understanding of the codes’ meanings are almost certainly losing a considerable amount of revenue each month.

Using EOBs to identify and reduce denials

The takeaway from this “horror story” above is to always read through all EOBs, from all payers involved, even when claims haven’t been denied, as this is the only way to know whether you are being paid what the contract states.  Use the following protocols for tracking denials:

  •  Use your EHR technology to run reports in your system showing all EOBs arriving electronically.
  •  Make a tally list of denial codes from payers.
  •  Enter this data into spreadsheet, reviewing data at month’s end for a ‘snapshot’ of where the problems lie from the list below.

Common denial reasons 

  •   Incomplete claims sent
  •   Charges not covered under patients’ plans
  •   Wrong codes and/ or modifiers
  •   Multiple duplicate claims
  •   Pre-certification/ pre-authorizations not included
  •   Insurance ended before patient was seen
  •   Wrong provider name
  •   Wrong patient name or unable to verify patient as insured
  •   Failure to include primary insurer’s EOB with secondary claims
  •   Workmen’s Comp claims: beware of “middlemen” who profit from your bottom line

Once the source of denials is known, group the types according to areas of responsibility:

  •   Providers
  •   Front office
  •   Billing department
  •   Practice’s policy manual

Working with a medical practice billing service

If you find that keeping up with multiple payers is costing too much time and money consider working with a professional medical billing and practice management service.  M-Scribe’s proprietary program automatically compares payments from all payers with their contractually allowed amounts. Claims are examined by experienced auditors and pre-adjudicators before submission, resulting in cleaner claims with faster, correct reimbursement. Call 770-666-0470 or for a free analysis of your practice’s individual needs.


Next Week: Monitoring Revenue and Debt Management

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