So another day and another batch of denials received in billing. Yet again, most of the denials are due to patients’ insurance being inactive (patient ineligible), demographic errors (e.g., address, DOB, etc.), coding inconsistencies (e.g., ICD not establishing medical necessity), credentialing (e.g., new provider not yet adequately enrolled), and for a limited number of claims, missing prior authorization. As usual, these reasons make up the vast majority of claims that were denied. AND, as usual, the billing team is getting reamed for a growing volume of AR most of which is the result of the aforementioned denial reasons. It is a maddening and vicious cycle that will repeat endlessly unless some outside of the box thinking takes place.
PMG has long been advocating to hold at least monthly, preferably bi-weekly, “meetings” between the billing team and clinic operations. These can be beneficial but in the end, the clinic staff are not accountable, even indirectly, to the billing team. Suggestions can be made but no one in clinic operations compelled to effect change. Most front desk staff report to a clinic supervisor or manager who ultimately reports to the VP or Director of Operations. The medical staff, including nurses, usually report to the Medical Director or Chief Medical Officer. The billing team usually reports directly to the CFO who personally is accountable for the CHC’s fiscal health, including steady cash-flow. In the end, as one of my business partner’s coined some years back, “The battle is won or lost at the front desk.”
Providers can be motivated to code correctly through various incentive, or (less desirably) through retributional, programs. The front desk staff are often their own island. They make mistakes… actually they are almost expected to make mistakes due to the entry-level nature of the position and typically VERY limited formal training… it’s just “normal” and accepted. That is just nuts. However, what if these staff reported directly to the billing leadership? Crazy idea? Maybe not.
If billing is responsible for the majority of cash flow at a CHC (true for most) AND billing can demonstrate that the primary claim denial reasons stem from front desk mishaps (again, true for most), one could make a compelling case to transition this chain of command to create a DIRECT down-line from billing leadership to all front desk staff. Critical to remember is the need to maintain emphasis on customer service… it’s never just about the money. However, think of the work the front desk does that dramatically and pervasively impacts cash flow, billing, and data capture (and this list is not all-inclusive):
- Eligibility Verification (Every patient, every visit, no exceptions.)
- Cash Collection (Sliding fee, straight cash for those who don’t qualify, and insurance co-payments/deductibles.)
- Insurance Status Designation/Selection (Which Medicaid or Medicare program, what if Medi/Medi, how does MVA or WC play into existing coverage?)
- Sliding Fee Determination and Category Capture (Enough said.)
- Charge Entry (CPT, ICD, ranking, linking, and payer centric rules… when is the T1015 appropriate and does one roll all charges into the T1015 or maintain pricing on each unique HCPCS code.)
- Management of Prior Authorizations or Referrals (Incoming and sometimes outgoing.)
The list could go on but if you are so inclined, you get the point. At a PMG Ops Assessment round table summary meeting with a moderate size CHC client, the CEO had clearly had enough of the back and forth between the CFO/Billing and the COO/Clinic Ops. He abruptly interrupted to ask my suggestion for resolving the demonstrable inadequacies at his front desk. When PMG suggested he allow the front desk to report directly to the billing team, the relief was palpable.
Nothing is ever perfect but if you are like most CHCs, struggling to maximize efficiency and squeeze every nickel in the name of optimal operations, break the mold and try something new. You might surprise yourself with the resulting sudden success.