I have assessed hundreds of Physical Therapy private practices in my career and I could tell you hundreds of different stories but instead, I am going to tell you about some of the most common stories I hear in just about every practice I have been in.
The process of taking a new patient, providing services and getting paid sounds so simple. I mean, why shouldn’t it be? Why is such a simple concept so complex? It all comes down to understanding the rules and regulations of each insurance carrier, knowing how to comply and implementing operational systems that will support your ultimate goal - getting paid from insurance and patients.
There are many things a front desk must do before the patient’s information gets to the biller. This includes providing benefit checks, entering patient demographics and managing referrals and authorizations. If any of these essential functions are not done accurately and timely, major problems will arise when it comes time for the biller to submit claims and get paid right the first time.
The front desk must check each patient’s insurance benefits before their first visit. We also HIGHLY recommend that your front desk encourage the patient to check their benefits as well. This helps to avoid getting conflicting information. If there is an issue, it can be addressed immediately.
There are many easy ways to get this job done fast and correctly. In most cases you can go through the insurance portal or clearing house but there will be times when you just have to pick up the phone and call.
We have seen many denials that could have been avoided if a benefit check had been done. For example, some of these denials might include patient’s insurance was terminated, the therapist is not in network with patients carrier and the patient has no out of network benefits. If treatment begins before these issues are addressed, there is a good chance that the biller will not be able to send a successful claim and get payment for that visit.
Entering Patient Demographics
Over 92% of denials come from data-entry errors made by front desk staff. Accuracy should be the #1 goal when it comes to entering patient demographics. This includes the patient’s name, their date of birth, and their member ID. The front desk may not notice their errors but when it comes time to bill the insurance, it’s the biller who will get a denial and have to correct the mistake and rebill. This process can be time consuming, and as we all know time= money.
A good way to let the front desk know of errors they may be making is to have the biller bring all data entry errors to the person entering data so they can be more aware of where they need to pay attention.
Referrals and Authorization
Referral and authorization management is something many front desk staff handles. The front desk must pay close attention to the insurance guidelines if a referral or authorization is required before treatment. You must have the authorization/referral in-hand when the patient comes in for the first visit or the claim will deny.
Some carriers require authorization after the evaluation has been completed. They need the evaluation and the appropriate form completed in order to approve more visits. And just as important as getting what you need before the patient is seen is to make sure that if the referral or authorization is expiring and the therapist wants to continue seeing the patient, they must get that paperwork in-hand before the patient continues or again, the biller will bill the visit and get a denial for no referral or authorization on file.
Keeping track of patient’s referral and authorization expirations can be made very easy if you use the tools provided in the billing software to manage them. There are reports that will give you the patients name, number of visits approved, used and the expiration date. Run these reports frequently and make sure you always have the appropriate approvals to avoid denials.
If you want run a seamless operation, strong communication between the front desk and the biller is key. The biller must feel comfortable bringing up these issues to the front desk and the front desk staff must have a clear understanding of what they must do before the patient is seen for treatment. If you are unsure if your front desk staff, biller, therapists, or office managers are aware of these crucial processes, you should invest in training from experts.
At DMBMCSI, our patented Administrative Power Center (APC) teaches your staff “The Proven Process for Getting Paid Right the First Time” by illustrating how these roles work together starting with the patient’s first phone call to the clinic. To learn more about our APC training and how it has improved the productivity of PT, OT, and SLP clinics all around the US, visit our website.
Over the years, many of my clients have been practically shut down all because they did not change the business address when they moved or added a location. There is a lot of stress when moving but not changing the business address can directly affect your revenue stream.
As a consultant I am called in to practices to evaluate the billing function and to answer questions like why are we getting so many denials, why aren’t our payments consistent, how do we know we are charging correctly, are we in compliance and most of all where is my money? And this is on the heels of investing in and implementing a new billing system.
We have all read articles on choosing the right system and they all promise that you will get better payments, stay in compliance, and your ability to charge and document will be enhanced, but the truth is, in order to get paid and get paid right the first time you need a competent, well trained staff and processes in place to support your goal – payment for services rendered.
There are great benefits to buying a new billing system, especially if it is an “all in one”, billing, scheduling and documentation system. Those that are not can be more difficult to guarantee an accurate flow of information back and forth. Investing in a new system for your practice can make a huge difference in staff productivity, improved documentation and charging for services.
Beware not all systems will work in your favor. Sales people will tell you things like: your profits will soar, you will always be in compliance and the system will do everything for you and the demo will be equally enticing – “it’s like magic”.
And there’s more - if you purchase this system you will begin to make more money almost immediately and the system is so easy to use. It’s great for a start-up, a small or large company, good for 1 or 100 sites and the list goes on. But before you choose, answer some questions.Why are you getting a new system? Who will help you choose a new system? Did you really drill down on the problems with the old system so you would not face the same issues again?
The truth is, there is not one system out there that will do “everything” the way you want but there are some that are much better than others. The best systems will hold their promises if there are skilled people maximizing all functions. Everyone will need extensive training. You have to put great info in, to get great info out.
Beware of the older or free systems out there that cannot bring your business to a new level. Those systems tend to keep you down and buried in the manual systems of entering charges, payments and have reports that are difficult to read and useless as a tool for managing the practice. Usually, you pay nothing and get as much to show for it.
Many sales people know how to use the system they are selling but they have little experience with using it in a real life situation such as your practice or in various states that have some specific requirements.
Here are some specific things to consider when investing in a new billing system.