There’s no denying that the current healthcare insurance reimbursement process is a hurdle for most private practices. Getting paid on time and in full takes coding skills, billing experience and seamless revenue cycle management (RCM) processes.
Whether you’re a new practice or a seasoned private physician, optimizing your reimbursement process is one of the most effective ways to increase revenue. And with added revenue, you can grow your business and care for more patients in your community.
Here are five steps you can take today to improve reimbursement from payers.
1. Create an Effective Insurance Verification Process
Knowing whether a patient has active, valid insurance is one of the first and most important steps of your reimbursement process. If a patient receives services at your practice but doesn’t have an active insurance plan, you won’t be able to file a claim and may not get paid for those services.
Creating an insurance verification process at your practice can help make sure you catch any inactive plans before a patient comes in for treatment. Consider running batch eligibility checks a week or two in advance and create follow-up steps for patients whose plans are inactive.
2. Send Patient Estimates to Increase Upfront Collections
One of the best ways to improve payer reimbursement is to collect that reimbursement upfront before you start the claim process. You can do this by sending payable estimates before the patient’s appointments. Patients are often more likely to pay a balance for services if they understand the costs up front.
You’ll also be able to increase upfront collections if you use a communication channel that your patient prefers. That means exploring options for SMS text and email estimates and statements. Meeting patients where they are and improving the patient billing experience builds trust and stronger patient-provider relationships. Ultimately, that means more payments and revenue for your practice.
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3. Establish an Efficient Documentation Review Process
One of the best ways to improve reimbursements is to establish a review process for your billing and coding. Beyond claim scrubbing, this process can help make sure you’re getting reimbursed as much as possible for patient care.
It’s important to note here that we’re not talking about upcoding (submitting a claim for a more complex or expensive service). Rather, we’re talking about using the most accurate and specific CPT code possible for the service you’re providing.
In the case of some evaluation and management (E/M) codes, it’s critical you use the code that aligns with the amount of time you spend with a patient. In mental health billing, individual and family psychotherapy codes vary based on the session length. For example, CPT code 90832 is for 30 minutes of individual psychotherapy but you can apply this code for a session lasting between 16 and 32 minutes.
E/M codes may also vary based on whether the service was for a new or existing patient, and it’s important to note this before submitting a claim. For example, in OB/GYN coding, CPT codes between 99385-99387 are for new patient well woman exams, while codes 99395-99397 are for existing patient well woman exams.
For more information on E/M codes and their different service levels, check out this resource from the American Academy of Professional Coders (AAPC).
4. Organize and Double-Check Payer Details
It’s essential that your team has a solid handle on your payer contracts and processes — this is a cornerstone of a smooth claim and reimbursement process. If your payer information is disorganized or inaccurate, you’re unlikely to get paid for the claims you’re filing.
Here are some important payer details and steps your team needs to consider when improving the reimbursement process:
- Make sure your provider credentialing is accurate and up-to-date. If you haven’t credentialed a new provider at your practice, you may not be able to submit claims for the services they provide. You also may not receive reimbursement if you submit claims for providers who are not credentialed.
- Don’t forget about insurance verification (see above!) and ensure your team always submits the claim to the correct insurer. This also applies to patients with secondary insurance plans — double-checking which insurance is primary vs. secondary is critical to avoiding claim rejections or denials.
- Verify that your claim submission software is mapped to the correct payer and payer IDs. Payers that accept claims electronically have a unique five-digit ID number.
5. Make Claim Corrections and Submit Reconsiderations
When a payer denies one of your claims, it doesn’t necessarily mean the process is over and you’ve lost that reimbursement. In other words, you don’t always have to write off the denied claim.
Instead of adding to your write-offs, create a process for correcting claims and submitting reconsiderations. If you make appropriate corrections and submit them along with detailed patient notes, the payer may wind up reimbursing your claim after all.
Alongside your claim correction and reconsideration process, make sure your team knows to collect detailed documentation for each patient. That means documenting every patient encounter, treatment, test and procedure, as well as any pre-authorization or pre-certifications you had to get before the treatment. This documentation can help support your claim reconsideration and increase the likelihood of full reimbursement.
Small Changes Can Make a Big Impact on Your Revenue Cycle
Making a few changes to your RCM processes can go a long way in improving reimbursements and helping your practice thrive. Whether it’s improving your insurance verification, sending estimates or finding a better way to review claim documentation, any of these steps will give your business the cash flow it needs to grow.
If you need help identifying areas to improve your RCM, Gentem has the billing and RCM expertise to make a difference with your reimbursement process. With industry knowledge, powerful analytics and AI-powered software, we focus on helping our clients identify and fix revenue gaps.
Want to see for yourself? Book an intro call today and our medical billing experts will show you how to increase your practice’s revenue.
