5 Admin Tasks that can be Lucrative to Your Practice
If you happen to be a provider who participates with healthcare insurance, then this post is for you. There are ways, administratively speaking, to increase revenue in your practice. I worked in an Acupuncture clinic for years where I was privileged to learn and develop a knowledge of how to decrease the likelihood of denied claims and partial payments. So I’m here to share them with you. Simply read along!
Dealing with insurance companies can sometimes be a tedious, back-and-forth, stressful process. You submit a claim, just to finally receive an Explanation of Benefits (EOB’s) 4 weeks later that give reasons why you’re not being paid. And to rub salt into the wound, the EOB’s further state that you cannot bill the patient for the balance. Frustrating… I get it.
Below are 5 simple, yet important steps you should consider taking, both prior to and/or after treating a patient.
1. Benefits & Eligibility
Verifying a patient’s benefits & eligibility before treatment is probably the most significant step in this list. Doing this first can save you the trouble of making several attempts to get a patient to pay, simply because you didn’t do your homework. Here’s some key information you might want to verify: Are you an in-network provider? Does the patient's plan include the benefits that you provide? Does the plan have a deductible? If so, has it been satisfied? Does the patient have a copay/coinsurance? Is this the patient’s only insurance provider? Is there a dollar amount and/or visit limitation? Is pre-authorization and/or a referral required?
2. Pre-Authorization Requests
A patient may have a benefit included in their plan, however, it might require approval from their insurance, otherwise, you’re not getting paid for it. This is one of the questions to ask when verifying eligibility. If pre-authorization is required, this is usually a simple process of filling out a form that typically requires diagnoses and procedural codes, along with other information regarding both the patient and your practice.
3. Claim Submissions
Duh. I mean, did I really have to mention Claim Submissions as one of the five steps?? Yes, and I’ll explain why. It's not simply submitting a claim that will guarantee reimbursement, rather it's ensuring you’re using the proper codes. Make sure that ICD and CPT codes are payable, and that the correct modifier codes are also being included. Proper coding is just an example of the many factors that contribute to proper claim filing.
4. EOB’s/Remittance Advice
An important part to understanding why a claim was denied or partially paid is to read over the EOB’s. An insurance company will include an explanation as to why a specific code or codes weren’t paid. This then gives you the opportunity to send a corrected claim if that is what will reverse the denial. What if the explanation just doesn’t make sense? Well, pick up the phone and call the insurance company. A rep can help fill in those gaps!
5. Appeals
Even after you’ve sent a corrected claim, an insurance company can still decide to uphold their initial decision and refuse payment. Perhaps they’ve determined that the treatment isn’t “medically necessary” for the patient. Whatever the reason, you can choose to go a little further than a corrected claim and dispute the insurance’s decision by submitting an appeal. Of course, an appeal is not an automatic guarantee of payment however, it does allow you the opportunity to provide substantial & supported reasons why your patient needs treatment, which can likely sway the denial into an approval.
After reading all of this, I’m sure you’re probably thinking to yourself, “I don’t have the time to do those things”. Well, my suggestion to you is to read this blog post and determine whether or not you need some assistance!
“The more you learn, the more you earn.”
