Back-end staff are critical to ensuring that you are getting paid for your work. They often deal with many different payers and their guidelines, which makes the upfront verification even more critical.
Communication with the back office is critical. Their input to the front desk is essential to detecting trending issues on your denials. It also allows them to put processes in place to stop or reduce these barriers that prevent reimbursement delays.
On the last installment of our Best Practice webinar series, Caroline Balestra, Business Process Analyst at Health Prime, gave an overview of some techniques you can implement in your back office to improve their processes.
Managing payer contracts
Before the visit, Back Office has a responsibility to communicate:
- Specific payer guidelines and payer benefit requirements: Help the front office understand any payer-specific guidelines and payer benefit requirements (if necessary) they must be aware of when booking patients. This can help dramatically increase reimbursements.
- Practices and providers payer contracts: One of the primary tasks for back-office personnel is properly managing these contracts. Also, your office must monitor payer reimbursement accuracy and billing performance. Organizations can negotiate better reimbursement rates and improve medical billing compliance if the team takes the time to assess payer performance and payment accuracy.
- Network status for practice and provider: Back-office staff must communicate the network status with the front desk and each provider. For example, not doing this could mean that maybe an in-network copayment was collected vs. a larger out-of-network deductible payment.
- Trend charge capture, rejections, and denials: Some practices often employ several staff members to flag charge capture issues and rework the charges. A system that trends charge capture data may improve back-end revenue cycle processes. Your Health Prime’s optimization team can report such trends through charge capture, rejections, and denials. Being able to trend the data and converse with staff, clinical teams, and providers can help prevent issues in the future.
- Assess and renegotiate as needed: Back-office personnel usually negotiate fee schedules with the contracted payers. Understanding how to work with payers to add CPT codes to your fee schedule or increase allowable reimbursement amounts on those schedules is critical to best practices where contracts are concerned.
AR & Collections
The complex web of different payer requirements can make claim submission a challenge. As Balestra explained in the second installment of our Best Practices webinar: For the Front Desk, prebilling verification and check-in can help prevent claim issues. However, the back office can also assist in getting claims paid.
How to prevent claim issues?
As back-end staff collect payments from payers and patients, they complete the healthcare revenue cycle by posting payments to the patient case and closing patient accounts. The front and back-end staff handle very different parts of RCM; breaking down the siloes between the two components can improve an organization’s financial performance.
Denials & Claims Follow Up
Some of the best practices in working with insurance denials are:
- Quantify the denials: You can’t manage what you can’t measure. Determine how many denials you have on a specific period and the reasons behind them.
- Develop a plan to avoid denials: Implement a solid denial management process. Understand the volume and root cause of your denials and what the payer will pay so you can make effective corrections and promptly refill your claims.
- Post $0 denials: Ensure your teams post all denials, including zero-dollar EOB. Posting zero pay will allow for better reporting and denial management.
- Create updated Billing rules: Keep a rules document for any billing rules you need to know about. This way, your entire billing team will function as one. If you work with Health Prime, each account has a document with practice-specific billing rules. Update the document frequently to avoid specific denials.
For resubmission and appeals, it is important to follow payer guidelines. Always be sure to:
- Review remittance remarks: Checking these remarks on an ERA or EOB can be extremely helpful in identifying that the issue is with any claim that has been denied.
- File a corrected claim electronically: Most primary new claims today are filed electronically. In addition to those, payers will also accept most corrected claims and secondary claims electronically. This makes resubmission to get a corrected claim on file much more timely. Your team should send corrected claims with all line items filled out, not just those that need corrections. Use the “original” claim number so the payer knows which claim to replace or void from their system.
- Submit appeals/reconsiderations online or use payer forms: Once you have determined an appeal can be submitted, ensure you are within the timely filing deadlines. Many payers will give you a deadline from the denied date to do this, so it’s essential to pay close attention to the dates or ask if you’re unsure.
- Know where to send an appeal: Utilize the proper form for reconsideration for applicable and use appropriate and effective language in those appeals.
- Track appeals: Follow and track those appeals to a decision once you submit the appeal.
Bridge the gap between the Front & Back Office
“An efficient communication between your front and back office is essential to run your medical practice effectively. A lack of communication between your team can lead to an ever-widening gap unless it is addressed appropriately” -Balestra explained.
To ensure long-term viability and sustainability, you must address the gap between staff members. This can help you improve the practice’s efficiency, revenue, patient satisfaction, and more.
Some tips to improve communications between the front and back office are:
Reporting for success
You will need the ability to run reports to ensure all the changes you have made to improve your front and back-office processes. These reports can help you identify if the implemented changes affect your metrics.
Our Health Prime Datalytics can help you measure your success with any recent workflow changes within the office. You can view different metrics at a glance but also dig deep as you need to into each area, which can help you identify where your focus might need to be at a given time.
Some focused reports you can pull out from Datalytics are clearinghouse acceptance, net collection rates/collection percent, A/R management, charge acceptance and no-show rates. There are other reports on the Health Prime Datalytics dashboard that you can utilize, but these are a few examples.
If you want to know more about Health Prime Datalytics, follow us on our Datalytics blog. Stay tuned for future articles in the blog series to see how our business intelligence platform has had a tremendous impact on physician practice revenue cycle management.
At Health Prime, we can help!
The healthcare revenue cycle is a complex process of managing revenue as it flows through an organization. Revenue cycle staff from the front and back ends should partner and constantly communicate to ensure revenue flows smoothly.
Health Prime offers partnerships with your practice to optimize your revenue. We have a track record of:
- Increasing the average percentage of claims paid after the first submission
- Improving net revenue to the practice
- Reducing controllable denial rates
- Improving claim payments
If you are interested in learning more about our billing services, optimization tools, or add-on solutions, email at [email protected].
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