The Treasure Hunt—Keys to Unlocking Radiology Reimbursement Patricia Kroken, FACMPE, CRA Radiology Business Management Association (RBMA)

The cost of poor performance Not unusual for a group with process inefficiencies to leave $250,000 - $500,000 on the table Process problems raise the ante--$1 million What would it mean if your group could increase the revenue per procedure by $3.00? $5.00?

How hard can it be? Patient Information Entered Insurance claim submitted Payment Front Desk Scheduling Billing

The Reality Patient Information Entered Insurance claim submitted Claim denial for error Denial assigned for follow-up Research: pull film jacket and/or call patient Correct claim and resubmit Payment Front Desk Scheduling Billing

Where do practices lose money? Charge capture Coding documentation Claims submission (clean claims) Insurance follow-up Denials management Private pay follow-up

Charge capture Sort and Match Charge Entry Coding Demographics Radiology Reports What happens when there is no match? Reports with no demos Demos with no reports

Charge capture Usually a manual process  The “stacks” build  Reconciliation is very difficult Technology is helping solve problems  Document scanning  Electronic “matching”  Edit reports of missing information

Coding documentation Dictation does not support codes Medical necessity denials  Need understanding of Medicare Local Coverage Determinations  Feedback from billing/coding to radiologists Ensure credit for what was done—but if it isn’t documented, it did not happen!

Claims submission Technology = success  Edit reports  Corrections of claims prior to submission Must also be able to follow up on claims status  Payor  Clearinghouse  Manual processes or lack of technology problematic

Insurance follow-up Most difficult process area to manage Usually dependent on the individual  Organization  Work habits  Ability to prioritize Workloads frequently unrealistic  Commercial insurance  Workers comp, MVA, Medicaid

Insurance follow-up More of an issue with hospital based practices  Inherent poor quality of hospital information  Denials for eligibility require Obtaining correct information Refiling to the correct carrier Completing the process within filing limits

Insurance follow-up Insurance “correspondence”  Often set aside due to workloads  “Easy money” A/R reports usually assigned by payor class  Dollar amounts not necessarily representative of work involved  Number of claims

Insurance follow-up Secrets to success  Assign priorities Dollar amount Age of account –Balance working old and new A/R buckets  Work correspondence daily  Document scanning Move work onto workstations and out of filing cabinets

Denials management Phases of denials management  Appeal of denied claims  Root cause correct to reduce/eliminate denials

Denial categories Missing/incorrect information Patient eligibility Prior Authorization Duplicate claims Filing deadlines Coding  Bundled/unbundled claims  Lack of specificity in ICD-9 coding  Failure to “match” ICD-9 and CPT codes Medical necessity/non-covered services

Denial trends

Denials management actions Prioritize: which correction would result in the greatest impact? Identify the source Work to correct operational problems  Training/resource issues  Process “drops”  Technology limitations  Dictation/transcription

Drilling down denials Distribution of denials by  Type (timely filing, etc.)  Site  Modality  Radiologist  Referring physician  Inpatient, outpatient, ER  Time of day/day of week

Private pay follow-up Often overlooked as revenue enhancement opportunity  Patients “too expensive” to follow-up because they “don’t pay their bills anyway” Fertile ground for hospital-based group  Patients classed as uninsured or private pay often have insurance Will ignore statements because “they provided that information at the hospital” Respond to collection letter—too late to file a claim

Passive collection processes Passive = patient must do the work  Respond to statement or letter Series of statements mailed Collection letters Turn to collection agency

Active collection processes work! Initiate phone calls to hospital patients with balances in excess of $100  Do they have insurance?  Would they like to pay by credit card?  Would they like to be put on payment plan?  Do they qualify for financial assistance? Private pay collector can generate $250,000 or more per year  May be able to set up “pass through” arrangement with billing service

Process improvement Radiology is comprised of a series of processes  Scheduling/registration  Performance of procedure  Billing/collections Correction of process problems will increase revenue…period.

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Thank you! Questions? Patricia Kroken, FACMPE, CRA Healthcare Resource Providers, LLC P.O. Box Albuquerque, NM /