Posted on October 15, 2018
While the occasional waiver of copayment obligations is permissible, the routine waiver of copay and deductible amounts is not. The federal Anti-Kickback Statute (AKS) prohibits the renumeration to a beneficiary of a federal and state health plans by any person or entity if the person or entity knows (or should know) that the renumeration is likely to influence the beneficiary to obtain services/items from that particular person/entity.
Posted on October 8, 2018
Qualified Medicare Beneficiaries (QMBs) are dual-eligible beneficiaries with low income (at or below $12,000); they are individuals who have Medicare and are also enrolled with Medicaid, and get help with their Medicare premiums and cost-sharing. Medicare providers may not charge QMBs for Medicare cost-sharing for any Part A and B covered items and services. This applies to all original Medicare and Medicare Advantage providers and suppliers. The providers and suppliers may bill State Medicaid agencies for Medicare cost-sharing amounts. Most states do limit their payments of Medicare deductibles, co-insurance, and co-pays for QMBs. Nevertheless, QMBs have no legal liability to pay Medicare/Medicare Advantage providers their cost-sharing amounts. Therefore, all original and Medicare Advantage providers, even those who don’t accept Medicaid, are not allowed to balance bill QMBs.
Posted on October 1, 2018
In our years in the medical billing industry, we’ve seen how credentialing can become a major problem area for our clients. We have one client whose new physician started seeing patients before being credentialed and approved by the payers — his services ended up being free — it was bad news all around. The practice lost money and the physician lost compensation.
Practitioners sometimes get (understandably) overwhelmed by the credentialing process, or find out after completing their initial submission that their approval just is not coming as fast as they need. To avoid a protracted approval process or a denial, it’s important to understand the complexity of submitting a successful credentialing application, and consider letting a credentialing professional handle the job — it will save you time and money, and let you keep taking care of the patients who need you instead of worrying about reimbursement.
Posted on September 24, 2018
“Would you consider bringing your car in for an extensive repair job that takes highly skilled mechanics to fix, and then drive your car away without paying?”
Of course not. None of us would. We have heard this and similar analogies from our clients and colleagues when lamenting all the revenue hits the practices are taking due to patient payment-related bad debt. The healthcare industry spends more than $400 billion annually on payments, billing, claims processing, revenue cycle management, bad debt, and collections. As patients’ out-of-pocket expenses continue to balloon, and high-deductible health plans (HDHP) become increasingly common, healthcare organizations must find a method of collecting more from patients.1
Posted on September 1, 2018
For our clients who are staring down huge amounts of bad debt related to services their patients haven’t paid for, the trend toward much higher patient payment responsibility can mean a hot-and-cold relationship with patients.
It’s possible this stems from a disconnect on both sides of the equation: Many patients don’t understand that they are now responsible for paying for more of their healthcare services, and some practices have not yet optimized their processes to make patient payment easy and efficient.
The world has shifted for many of our clients and healthcare organizations of all type and sizes. According to the Medical Group Management Association’s (MGMA) research in 2010, $1 in every $4 of payments comes from patients, and that trend has only continued and intensified since then.1
The patient wields unprecedented power and responsibility in the new healthcare terrain, and many healthcare organizations aren’t doing enough to facilitate better patient relationships and smoother patient payments, which is directly impacting revenue.
Posted on August 15, 2018
These are the billion-dollar questions. Similar to a patient with an ongoing condition asking, “When will I be cured?” the answer is always going to be, “Well, that depends on a lot of factors.” That is where we come in.
Revenue cycle optimization is not a one-size-fits-all prospect. Nor is it a process with a discrete start and end date. Think of it as a living organism, affected by any number of variables that can shift from year to year, week to week, even hour to hour. Revenue cycle management is not a “build it and leave it” task. You must shepherd this complex organism through the life of your organization and keep it as healthy as possible.
Posted on August 6, 2018
Finding new ways to optimize your revenue stream doesn’t have to be an exercise in frustration. Looking at small tweaks to tighten up gaps can be an easy way to give your revenue numbers a boost, and it can be done whether you’re just at the beginning stages of evaluating your revenue lifecycle management or if you have a robust system in place.
Our clients are often astounded at how much loss they could prevent by a few simple checks of their physician fee schedule. We recently worked with a family medicine practice in which a few small tweaks netted several thousand dollars monthly in additional revenue that it had been losing simply by not paying close enough attention to its insurance payers’ explanation of benefits (EOB) documents. Taking a moment on a regular basis to optimize your physician fee schedule can yield previously “hidden” revenue more often than many physician practices realize.
Posted on July 23, 2018
We were recently leaving a meeting with a client’s billing manager when she said something that made us pause. “I wish the whole team here were as gung ho about revenue cycle management as you guys are,” she said.
The Americanization of the term has come to mean “enthusiastic” or “zealous.” In the original Chinese, gung ho means “work together.” If you think about it, all organizations will benefit from that attitude at all levels, especially healthcare teams in the midst of some major transformations in our industry. Following sweeping regulatory and legislative changes like the Affordable Care Act, we’re seeing huge increases in patient payer responsibility, an emphasis on data, and a seismic shift in the insurance and claims sector.1
Revenue cycle management remains one of the most important areas of focus for healthcare organizations. Creating and nurturing an organization-wide culture of revenue cycle management can foster that gung ho attitude where everyone pulls together toward the common goal of excellent patient care and healthy revenue.
Filling Out Your Dance Card: Determining Which Revenue Cycle Management Partner Is Right For Your Practice
Posted on July 9, 2018
Just recently, a longtime partner of ours, a diagnostic services center based in the West, reported to us some truly amazing revenue numbers from last year’s third quarter. PRN is so proud to have been a part of their story from the time they were just one small location barely beginning to tweak their revenue cycle factors.
Working with a revenue cycle management partner should be more than just a decision about “outsourcing” or staying “in-house.” With PRN, those kinds of distinctions feel arbitrary — we want you to consider us as dedicated to you as any in-house department responsible for optimizing your revenue. Typically, we start working with our clients when they reach a size where in-house billing, collections, follow-ups, coding, proofing claims, accuracy audits, tracking HIPAA and other laws, and all the big and small things that make up a healthy revenue cycle, has simply become too much.
Posted on June 11, 2018
Jamie Hernandez, a 41-year-old former Division III soccer player, walks into a physician-owned outpatient surgical center for a knee arthroscopy. Due to an innocent keystroke error, a staff member sends the invoice for Jamie’s procedure to Jaime Hernandez, a 72-year-old retiree who had a total knee replacement at the center a couple of years ago. The error is eventually discovered, of course, when Jaime calls confused about the invoice, and a replacement invoice is quickly sent out to Jamie. By then, however, several weeks have passed, and payment is delayed.
We see scenarios like this play out at our clients’ facilities every day. Nicholas Payne comes in for an MRI in January and ankle surgery in March and ends up with two patient records, under Nicholas Payne and Nick Payne. Claire Boswell has two records, one with her birth year as 1987 and the other listing her as born in 1978. Bill Johnson is one of nine Bill Johnsons in the database, but three of the patient records belong to him, with three different addresses listed.
These things happen—any organization dealing with a lot of data and customer information is bound to end up with a duplicate record problem. Many of our clients are surprised to learn that what seems like a simple administrative issue can cripple your revenue cycle if you let it get out of control. Duplicate patient records and an inaccurate master patient index (MPI) affect your bottom line in multiple ways that can all be detrimental to your organization.1