Maximizing Practice Profitability: Why Modern Clinics Are Transitioning to Dedicated RCM Services

Being self-employed in the health-care setting is a challenging yet rewarding undertaking. The reality of running a private clinic involves providing patient care with the level of attentiveness and compassionate, as well as facing a myriad of administrative hurdles, including complex insurance policies, difficult regulatory environments, and complicated billing codes. Internal billing is a significant challenge for practices, and can lead to lost revenue, staff turnover and regular disruption of working arrangements.

Many clinics believe that having the billing function in-house would give better control of finances. Commercial and government payers have turned far keener these days, however. In a more traditional office setting, the front office person has an impractical workload of duties, such as greeting patients, scheduling appointments, checking insurance, etc. and claiming payments. When administrative processes are disjointed, it can result in substantial losses each month from minor administrative errors.

The Operational Vulnerabilities of In-House Medical Billing

• Missed Modifier Codes: Administrative staff can get overwhelmed with the need to add the critical clinical modifiers, such as Modifier 25 and Modifier 59. The payers' automatic clearinghouses reject these claims and thus set up back-order and delay cash flow.

• Delayed Prior Authorizations: Staff waiting hours on hold and/or sending hours of faxes to insurance adjusters for prior authorizations. These treatments are delayed until they have been administered, which delays critical therapies, disrupts clinical treatment plans, and results in patient frustration.

• Bad Debt: Administrators are overwhelmed and forget about accounts receivable (A/R) that have been over 30 days, 60 days and 90+ days old. At some point, these claims fall past time limits in the statute and they are considered uncollectible bad debt.

• Staff Burnout: Staff expected to perform all three functions of receptionist, call coordinator, billing specialist is a morale killer, cost of turnover, and a greater incidence of clerical error in a myriad of daily interactions.

The 5 Core Pillars of a Modern RCM Framework

Don't fall into administrative hassles that affect your clinic's profitability with the 5 pillars of a Modern RCM Framework. By outsourcing to professional healthcare revenue cycle management services, the entire process becomes easier and more efficient, eliminating the disjointed nature of internal operations, and establishing a process that includes five pillars:

1. Real-Time Eligibility Verification & Early Prior Authorization: Almost 100% of billing disputes are related to Real Time Eligibility Verification & Early Prior Authorization. An optimized RCM system checks insurance coverage, copay, deductible, coinsurance, and secondary payer rules directly in your EHR, at the time of scheduling. Authorized dedicated PAs coordinate the clinical chart notes and receive payers' approvals well in advance to avoid the cancellations, reduce patient anxiety and prevent front-end rejections.

2. Certified Coding & Algorithmic Claim Scrubbing: Medical billing calls for constant continuing education and exactness. Credentialed AAPC and AHIMA billing specialists review all claims and keep up with ICD-10, CPT and HCPCS updates annually.

3. Proactive Denial Management & A/R Follow-Up: Don't consider denied claims as lost revenue; Proactive Denial Management & A/R Follow-Up A/R recovery specialists are specialists who are full-time to understand the reasons behind each denial, correct documentation or modifier problems, and appeal claims to commercial payers, Medicare and Medicaid in a systematic way -- a claim's first pass acceptance rate can reach up to 98%. Days in A/R remain average (30 days.4) with ongoing follow-up by the payer.

4. Automated Payment Posting & Digital Patient Statements: There are a lot of manual payment ledgers that can cause discrepancies and are time-consuming. An end-to-end Electronic Remittance Advice (ERA) framework is used to reconcile the ERA files directly with your practice ledger, on the fly. Patient balances sent electronically as clear digital statements and itemized billing to ensure patients can pay promptly without chasing the bill down the clinic, via a secure online portal. This holistic approach ensures that secondary and tertiary claims are submitted on time after submission of primary claims, avoiding loss of secondary claims.

5. Business Intelligence & Practice Analytics: For sustained financial health, all the information has to be transparent. Customized comprehensive Business Intelligence (BI) dashboards give clear visibility to important metrics like net collection ratio, clean claim percentage, days in A/R, and turnaround time with the payers. These actionable findings, based on data, help practice owners determine clinical profitability trends, deal with operational roadblocks and make informed, data-driven business decisions for their future growth.

In-House Billing vs. Dedicated RCM Services

Reclaim Your Focus on Clinical Medicine

Healthcare professionals enter medicine to heal patients, not to argue with claims adjusters or decipher complex clearinghouse rejections. Keeping employees at high base wages, benefits and expensive software licenses pulls your attention away from patient care and takes a toll on your finances. At the same time, small and medium-sized clinics face the constant problem of software license fees for billing software, clearinghouse fees and software training.

You'll eliminate all the operational delays, missed earned clinical revenue and the need to work in silos, while your healthcare team will be able to concentrate on delivering superior personalized patient care ready-on-demand for your community and all with dedicated, HIPAA-compliant RCM services beginning at only 2.99%.