In an ideal world, patients would know their benefits like the back of their hands, we’d have a global payer list, and every claim would be accepted on the first try. But the world is not a perfect place, and there’s only so much you can control. Still, you can do your darndest to get close to the perfect billing workflow. Perfect—or near-perfect—billing begins way before you even create the claim. So, let’s start at the very beginning: the initial visit.  

The initial visit is everything.

Basically, the first visit determines the success or failure of every subsequent claim for an individual patient. Plus, it often brings the highest payment—so treat it with care. Say someone wrote down the wrong address for the payer—maybe just one number was off—and you end up sending the claim to the wrong carrier. You’d almost certainly receive a denial on the basis of eligibility. Of course, if this happens to you, you’ll correct the denied claim and appeal the decision, but by that point, you’ve already wasted valuable resources. Clearly, it’s much better to make sure that all claim information is correct from the get-go.

The Front Office Factor

Generally speaking, your front office should follow the tips below to ensure clean claims from the start:

  • Put your patient data collection forms online. By the time your patient comes in for his or her first visit, you’ll already be ahead of the game.
  • Verify insurance. It would be great if your front office staff could simply swipe an insurance card like a credit card and have all the patient’s insurance information in a snap, but until that happens, you’ll need to pick up the phone. During that critical call to the payer, you must confirm:
    • patient eligibility,
    • coinsurance or copay,
    • deductible,
    • benefits cap,
    • where to send the claim,
    • whether the payer requires specialized forms or additional documentation, and
    • whether the payer requires authorization. Some payers will retroactively authorize services, but for those that don’t, you need authorization before you begin providing services.
  • Make a copy of the insurance card and keep it on file for reference.
  • Confirm that you have the correct patient demographics.
  • Have the benefits conversation immediately. (Be sure your staff is ready and willing to have this kind of conversation.) Ideally, you’ll want to confirm patient understanding in writing, too. It’s as simple as including a financial responsibility section in your patient data collection forms. Make sure your patients read and sign it.
  • Collect any coinsurance or copay. (And continue checking and collecting the patient’s balance at each visit.) If you can’t get an accurate amount from the payer, make an educated guess as to what you think the charges will be; then, collect them before providing services. It’s easier to issue a refund than it is to chase down unpaid balances.
  • Put a payment card on file and get the patient’s permission to charge it at every visit.
  • Know the claim submission requirements for your top five local payers. You probably work with many more payers than that, but if you have a firm handle on the top five, you’ll save yourself a lot of time and headaches.
  • Understand timely filing guidelines. Of course, you always want to file as quickly as possible, but your idea of ASAP may not be the same as your payers’—and a clean claim is worthless if you don’t file it within the required timeframe.
  • Re-verify patient insurance when appropriate. Did your patient just get a new job? Has it been a while since the patient’s last visit? Did you recently have to flip a page on the wall calendar? Then it’s time to re-verify insurance.
  • Install a 72-hour verification period policy. That means your front office must check benefits within 72-hours of the patient’s appointment. Not only does this help ensure patients are up to speed on their financial obligation, but it also allows you to inform a patient if he or she has a high deductible. That way, if the patient decides to cancel, you still have time to fill the open time slot. That’s a win-win.

Check-outs are just as important as check-ins.

If your patients check in, but they don’t check out, then it’s time to change your procedure. A concrete check-out policy can help your staff ensure they collect any cash left on the table at check-in. How? It affords them another opportunity to collect information or payments they failed to obtain at check-in. Plus, they’ll have a chance to schedule patients for their next visits right then and there instead of trying to track them down by phone or email after they’ve left the building.

The back office better have your back.

Your front office has collected all the patient information, the therapist has finalized his or her notes, and the back office sends the claim on its way to the payer. But somewhere, somehow, wires got crossed or numbers were transposed—and the claim gets denied. Bummer, dude. Wouldn’t it be nice if payers offered suggestions on how to correct denied claims? Well, we can all keep dreaming, but for now, it’s on you to determine where the claim failed to cut the mustard. But don’t take too long getting to the bottom of it; the odds of reimbursement decrease greatly after you get a rejection, so you must follow up on denials immediately. The longer you wait, the less likely you are to receive any payment at all.

Beyond quick re-submissions, following trends can do wonders for your back office billing success. You have to figure out:

  • where your claims are getting bogged down,
  • which claims are getting denied the most, and/or
  • what’s causing your claims to be denied.

Then, work to resolve those issues. Also, pay attention to fee schedule updates (and keep an eye out for claims that are getting paid out at 100%) to ensure you aren’t leaving money on the table. An unknown pay schedule increase of only a few dollars can result in huge losses for your clinic over time. And as for those old collections accounts, the biggest mistake you can make is not having an outside billing agency—or someone at your clinic—to call patients who have outstanding bills.

Automation is the ticket to error-free acceptance.

Clean claims are the bread and butter of billing—but they can be especially difficult to produce consistently. There are more than 3,000 payers—and each one has its own set of guidelines or regulations you must follow to get paid. That’s why electronic claims submission and reimbursement is where it’s at. While it might seem scary to put your revenue in the hands of something that, well, doesn’t even have hands, automation is the fastest and least cumbersome way to get paid. Billing services and software will scrub your claims for you, ensuring that your claims have all the information they need. Plus, you can auto-post your reimbursements. There’s no paper copy or receipt, but you always have the option to check the payer’s website for claim status and payment.

Ultimately, creating the perfect billing workflow comes down to taking accountability for your business. There will always be keying errors (we’re human, after all), but everything else is controllable, so do the work upfront to ensure you create a clean claim the first time—every time.