Pain Management Clinic Finds $300,000 of Hidden Revenue
Case Study
The report revealed insights and identified opportunities where the practice could improve the billing operations, collections, and cash flow.
Practice Profile
Location: Washington State
Specialty: Pain Management
Physicians: 2
Locations: 2
Services Provided
Key insights discovered from a 12-month retrospective analysis
Lost Revenue Due to Preventable Denials
This pain management practice had adjusted (i.e. written off) approximately $300,000 in revenue for preventable reasons. The root causes can be broken down into the following categories:
- Medical necessity (12 %)
- Insufficient documentation (27 %)
- Coordination of Benefits (16 %)
- Investigational procedures (15 %)
- Out of Network (30 %)
Claims Denied for Preventable Reasons
Out of Network Denials and Adjustments:
Blue Cross WA & AK Premera claims rebilled to correct Insurance/plan type after initial denial that can be prevented. 948 claims rebilled to Blue Cross in the last two months. This represents a significant increase in cost due to “re-working” the claims.
The practice took a more proactive strategy by using Gentem’s Real-Time Eligibility (RTE) feature. The practice eliminated rebilling with GentemRTE by identifying and flagging inaccurate insurance plans ahead of time before the practice submitted claims.
Negative Adjustments on Medicare Claims:
The practice’s physicians received a negative adjustment on Medicare E/M services due to a negative MIPS adjustment.
Certified Gentem Advisors assist the practice managers in realtime on MIPS attestation and submission of measurements.
Payment Posting Lag greater than 365 days:
Gentem identified payments received between January to August 2019 that were posted on October-December 2020.
The practice established clear metrics and processes using the Gentem Dashboard for a streamlined workflow. This system helped better define timelines for payment postings. Payments were then posted within two days of receipt and monthly payment reconciliation. They were able to identify missing payments with follow-ups using check tracers.
Controllable Write-offs:
Gentem will review the ‘Medical necessity’ and ‘Insufficient documentation denials’ in order to provide solid recommendations to the practice. These are to prevent claim denials and improve clinical documentation.
Keeping up with the latest updates and market changes helped the practice continue to adjust and thrive. Gentem advisors provide ongoing educational updates by outlining the latest in payer policies to prevent medical necessity and insufficient documentation denials.
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