Is there revenue hiding under the baseboards in your practice? Not likely, but there are likely revenue leaks occurring that are costing the practice thousands to hundreds of thousands of dollars a year if not properly monitored.
1. Missing Encounters.
The patient was seen, services were rendered, yet no bill was generated. As long as the patient was scheduled in the practice management (PM) system, reports can be generated that match an appointment to a corresponding claim. Each system has its own name for that report, we generically refer to it as the “missing encounter report.” Office visits are easy to track as virtually all office visits are scheduled in the PM system. How about surgeries? Are they scheduled in the PM system so that they can be appropriately tracked?
Another challenge is ensuring services performed while on-call are billed. How do the physicians relay the information to the billing office that they were called in for a hospital consultation or performed emergency surgery at 2:00 am? Without proper checks and balances, practices can leave substantial money on the table.
2. Bilateral Procedures.
When a bilateral procedure is billed, it’s imperative that the charge is doubled. Payors pay the lessor of your billed charge or their allowable. When a bilateral procedure is billed without doubling the fee and that fee is less than what the payor would allow, you lose revenue. When payors pay 100% of your billed fee, that’s a flashing sign that your fees are too low. One remedy is to include a bilateral procedure code with the fee already doubled, that way staff don’t have to remember to do the math.
3. Underreported units.
The most common billed unit is one. So, for services that are greater than one, special care has to be made to ensure the correct number of units are reported. Being paid for one unit of Kenalog is less than being paid for four units. For allergy practices, only billing one unit of allergy testing or one unit of allergy mixing is a significant revenue leak. Payor rules can be programmed into the PM system to alert when procedures are billed with units below a certain threshold.
4. Consultation codes.
Although Medicare discontinued paying for consultation codes, a fair number of commercial payors still pay for them. Treating all payors like Medicare can cost the practice money. Investigate if your payors will pay for consultations.
5. Writing claims off in full.
Too often we see claims that are written off in full to “CO-45 contractual adjustment.” We doubt that you have negotiated with any payor for an allowable of $0. However, we find too many examples of claims being written off in full that were not appealed or corrected. Sometimes it’s a classification issue, for example, the claim was denied due to no precertification. Upon further review, it was determined that the precertification was indeed overlooked. In that case, it would be appropriate to write the claim off. But, it should be written off to no precertification, not contractual adjustment. Other times, claims are arbitrarily written off to contractual adjustment without any further review.