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Revenue Cycle Management

5 Ways to Maximize Insurance Reimbursements

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Managing the revenue cycle efficiently is no easy task and requires your constant attention. Each phase of the Revenue Cycle - from the moment a patient is scheduled for an appointment until the time payment is received from the insurance company - is equally important to maximizing insurance reimbursements.

It is vital for the financial stability of the hospital or physician office to have a process in place for each phase of the revenue cycle. Not only will you receive payments in a timely manner but will also reduce the burden on the billing staff, keep down administrative costs, and most importantly maintain a positive rapport with your patients.

Insurance Verification

The revenue cycle should begin prior to the patient's arrival. As soon as the appointment is made, the patient's insurance information needs to be verified. Because insurance information can change at anytime, even for regular patients, it is important that the provider verify the member's eligibility each and every time services are provided. The benefits of obtaining insurance verification prior to the patient's arrival include:

  • Reduce claim denials due to invalid patient information
  • Obtain prior authorizations
  • Ensure faster registration and/or enable pre-registration
  • Verify which medical services are covered/non-covered
  • Obtain information about the patient's co-pay, coinsurance and deductible
Upfront Collections

The fastest way to increase cash flow and improve collection rates is to collect patient responsibility up front. Patients are less inclined to pay or are difficult to reach once the services have been performed. Rather than waiting until the collections stage of the revenue cycle, providers should take advantage of discussing financial issues and collecting patient payments early in the process. Notify patients prior to their arrival of what their estimated responsibility will be and make them aware that payment is required prior to services being performed.

In addition, financial counseling can help determine a patient's eligibility for public assistance, charity care or payment plans, which can also be difficult to do once the patient has already received treatment. This process will assist with minimizing the billing staff workload as well as improving collection efforts.

Coding Clean Claims

Submitting a clean claim is the only way to guarantee correct payment the first time. Billing correctly the first time will prevent delays in claim processing and in some instances a higher reimbursement. A clean claim is one that is accurately completed in accordance with the insurance companies and federal government's billing guidelines.

A major challenge for providers is identifying and adhering to carrier specific rules related to coding. Although coding issues are not the only reason for insurance denials, they can sometimes be overlooked due to lower reimbursement as opposed to other denials that may have no reimbursement such as incorrect patient information. It is really important that the coding and billing staff keeps up to date information on billing guidelines for all carriers.

Remember to make sure that the patient information is accurate to prevent denials as well.

Prompt Handling of Denials

Most insurance carriers are required to pay the claim or provide a denial in writing within 30 days of receipt. A claim that has not processed within 30 days is subject to interest penalties, however, being paid interest is not in your goal. Your goal is to get payment as quickly as possible. Taking a proactive approach to handling denials can improve AR days substantially.

  • Have your billing staff follow up on claims in 10 business days of electronic claims billed and 15 business days of paper bills to make sure the claim has been received and to find out if the claim has already been processed.
  • If a claim has already been denied, a claim representative can tell you over the phone instead of you waiting for the denial to come in the mail. Immediate corrective action can be made.
  • If a claim has not been received at all, you are aware much sooner in order to resubmit the claim.
Payment Review

The final step in managing the revenue cycle is to review payments for accuracy. Make sure you are receiving the full reimbursement per your insurance contract. Sometimes lower reimbursement may be made due to a coding error or possibly a payment error made by the insurance carrier. Any inconsistencies should be addressed promptly so they can be resolved in a timely manner.

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