Performing analysis of a practice to improve performance from a clinical and financial standpoint is extremely important in the modern age of healthcare. The market is ever-changing. New regulations, coding and billing changes, and reduced reimbursement require an in-depth understanding in order for a practice to make well- informed decisions. Performance and proficiency and quality-based medicine or value-based medicine is the focus of all payers.
Fee Schedule Maintenance
The fee schedule has to be kept up-to-date. If the fee schedule is not updated, it creates a situation where the charges being filed with insurance companies/payers are less than allowed amounts. This can drastically effect your revenue cycle. We can review all insurance company contracts and fee schedules and make changes to ensure the maximum possible reimbursement is achieved. This is time-consuming for the practice, but with experience solving this problem we can do it efficiently and cost-effectively. We can use other aspects of your practice, such as quality measures, in negotiating insurance contracts. The fee schedule is the starting point for many aspects of your business.
Procedure Code Analysis
Practices vary widely in their use of procedure codes. However, the need to understand the use of the proper code and accurate use of combinations is what makes the difference in reimbursement success. Also, many times risk of audit is reduced and quality measures are met by utilization of appropriate codes. These codes can be compared to national data and implementation in your practice. This analysis also allows us to identify possible services you are performing but not billing. Corrections such as this can have a significant impact on your revenue cycle.
Many practices use procedure codes that require the use of modifiers, and not only one, but a combination of modifiers. Reimbursement is directly effected by these modifiers. They are specific and require expert knowledge to be used in many instances. A practice can have billing analytics performed and from this the accurate use of the modifiers can be provided. Education has to be ongoing in regard to modifiers.
Many practices overlook the need to analyze providers on an individual basis. Providers need to be compared to their peers within their own practice and to national standards. This helps to ensure quality measures are being met, improves reimbursement through insurance contract negotiations and prevents recoupment by insurance companies/payers. Most importantly, this analysis will allow patient care improvement, which strengthens any practice. Many physicians believe the use of low levels of evaluation and management codes will keep them off the radar of audits. The opposite is often the case, as this does not compare to national data. The constant misuse of coding by a physician can decrease revenue for the entire practice. Simple problems many times are also identified in this process. Practices will allow providers to see patients who have insurance with which the physician does not participate.
Practice managers can be unaware of losses that are being created by low reimbursement as compared to cost involved with certain procedures or ancillary services. The procedures which have direct cost involved with them have to be analyzed on a routine basis to prevent loss. Direct and indirect costs associated with all aspects of the practice have to be taken into consideration when budgets are prepared and negotiations with insurance companies are performed. These analytic measures help to ensure a positive revenue cycle.