Major challenge in successfully running wound care practice is receiving timely and accurate insurance reimbursements. Medical practices can efficiently manage overheads if they receive accurate insurance reimbursements on time. One of the key factor in receiving reimbursements for wound care practice is understanding payer requirements. If they are not known/met you are significantly increasing the chance the claim will be rejected (have an administrative or clinical error) or denied (deemed unpayable), resulting in extra office processing costs of $25–65 or more per claim. Another challenge is understanding ‘write-offs’. If you accept assignment, the difference between the billed and allowed amount is the write-off. Write-offs that physicians, especially those in private practice, need to focus on are those due to patients not paying, as well as write-offs due to a denied or rejected claim not being reprocessed, as these are draining revenue from the practice and reflect revenue the office can control. In this article, we discussed other factors that affect timely and accurate reimbursements for wound care practice.
Factors Affecting Timely & Accurate Reimbursements for Wound Care Practice
Insurance Payer Requirements
Understanding payer requirements is essential step in receiving timely and accurate reimbursements for wound care practice. Revenue cycle activities include scheduling, staff responsibilities, medical record documentation, charge capture, coding, charge entry, claims transmission, payment posting, denial management and working accounts receivable. Out of all these RCM activities you need to highlight activities that require modifications as per payer requirements. Primary focus must to understand payer medical necessity/clinical requirements for the test, procedure, service or care. Fortunately, major insurance payers have medical necessity and clinical documentation requirements available to you. This information is to be found on the payer websites under names such as clinical policies or clinical bulletins.
Aligning Office Processes
The best way to determine where revenue is being lost, excluding write-offs is to generate a report indicating what services result in a high volume of claim rejections or are denied. If you outsource billing services and your office is not capable of generating current claim status reports without help from the outsourced billing provider, there is a lack of transparency and a new billing service needs to be used. Based on the reports, you might focus on high-value services, lower-value services that have a high percentage of claims rejected/denied or you might just start with addressing the insurance payer that results in the most revenue being rejected/denied.
Your office needs to be proactive so they can meet or support payer requirements. You know where medical necessity and clinical requirements can be found, but do the physician/clinical staff have a template or checklist that will help them to obtain and document that critical information? Within 48 hours of the appointment being made, does the physician briefly look at the reason for visit and indicate test, procedures and services the patient will likely need? If so, administrative staff can begin work on obtaining prior certification. Start by maybe doing this with five established patients a day with a goal of doing this for all patients.
Some of the administrative activities that will help to receive timely & accurate reimbursements for wound care practice are:
- Performing 100 percent patient eligibility and benefits checks
- Ensure every test, service or procedure that is rendered is documented and that the charge capture sheet is current
- Have a backup plan in place so when primary coder(s) are absent, coding can still be done without delaying the generation of revenue
- Services rendered need to be input on the claims forms with minimal delay, within 24 hours of receipt
- Electronic claims should be sent multiple times throughout the day and paper claims need to be sent daily
- Payment posting should include the processing of all payments within 24 hours of receipt
- Promptly distributing for rework all rejected/denied claims, as well as those that were underpayments
- Verifying claims were received, checking on the status of claims (within two days of the date that the claim should have been processed).
Legion Healthcare Solutions is a leading medical billing company providing complete billing and coding services. We can assist you in receiving timely & accurate reimbursements for your wound care practice. With our assistance in medical billing and coding, you can focus on prime function of your practice i.e., patient care. To know more about our wound care services, contact us at 727-475-1834 or email us at firstname.lastname@example.org