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How Medientsky Billing Helped a 180-clinic Medical Group to Achieve Their $5 Million
Discover how Medientsky Billing helped a 180-clinic medical group boost collections to $5 million in two months by revamping their RCM operations.
Table of Contents
Introduction
In January 2023, A 180-clinic Medical Group reached out to us to provide them with a consultation on their entire revenue cycle operations. Their medical billing service-providing company that manages a range of healthcare facilities was managing their complete RCM operation and the medical group board members did not find any improvement whatsoever. To facilitate the restructuring process, The medical group board members teamed up with Medientsky Billing, an international firm specializing in healthcare RCM services and consulting for advice. The first step during this period is to set up an RCM VP to oversee the streamlining of operations of their 180 locations.
How we helped them in filling the RCM VP position?
Frequent turnover of VP of RCM in this 180-clinic Medical Group is linked to the continuous demand for monitoring the revenue cycle, which puts significant pressure cannot be handled by their CIO and CEO as they have more administrative tasks on their hand and RCM processes need dedicated attention and there were other underlying reasons were:
The main factors were:
- Insufficient expertise.
- Inadequate support staff for roles such as RCM managers, supervisors, etc.
- Lack of an efficient RCM system.
- Unforeseeable working hours.
- External outsourcing partner’s negligence.
The 180-clinic Medical Group faced challenges due to a high turnover rate in revenue cycle leadership, leading to financial losses and impacting patient satisfaction. They sought assistance from us to find a suitable VP of RCM. We analyzed their organizational structure and identified gaps that had caused previous VPs to leave. Their existing outsourcing partner was not transparent as to the data presented in terms of collections, adjustments, and unpaid receivables. We conducted a detailed analysis of their revenue cycle operations and developed a job description and qualifications for the VP position. We screened and interviewed candidates and presented a shortlist of qualified individuals to the health system. They ultimately hired a candidate with a strong revenue cycle management background, resulting in improved revenue cycle operations. We also helped streamline their RCM processes. Our revenue cycle recruitment and consulting services aided the 180-clinic Medical Group in finding a talented and experienced VP of RCM who could lead the department effectively and bring positive change to the organization. MR. Manick Rajendran a close colleague with Medientsky Billing who has worked as VPs and CEO of various hospitals agreed that he will be the interim VP until the medical group finds a permanent resource.
Using technology and MGMA-proven benchmarks to analyze their Accounts Receivable:
This medical group is one that requires the utmost precision and accuracy in medical coding, billing, and authorizations. Failing to maintain this level of accuracy resulted in significant financial losses. Unfortunately, the scenario described by their CIO and CEO above highlights a common issue faced by many healthcare organizations where their billing company fails to meet the necessary standards, leading to mounting financial and administrative problems.
Phase 1 – Revenue analysis and audit:
According to our LRRA (Lost Revenue Recovery Audit), the medical group in question was experiencing significant problems with their billing company. The issues were so severe that they had resulted in a worrying scenario of 30+ days of accounts receivable (AR) worth over $2M and 120+ days of AR close to $5M. These are alarming figures that highlight the severe financial impact that can result from coding and billing issues in the healthcare industry.The first major issue highlighted in the dataset is the 30+ days of AR worth over $2M. This means that the medical group had outstanding payments for services rendered over 30 days ago, resulting in a significant financial burden for the group. This delay in receiving payments can cause cash flow issues, affecting the medical group’s ability to pay its staff, maintain its facilities, and purchase necessary equipment.The second issue mentioned is even more significant, with 120+ days of AR close to $5M. This means that the medical group has outstanding payments for services rendered over four months ago, highlighting a severe problem with the billing company’s practices. The financial impact of this is staggering, as the medical group is effectively losing out on the $5M that it is owed.
Phase 2 – Identifying problems and providing solutions:
| BILLING ERRORS | MEDIENTSKY BILLING ACTIONS |
|---|---|
|
BILLING ERRORS Missing Codes – Incorrect or incomplete codes entered and billed. |
Conducted a pre-billing audit to ensure that all billable codes for the Date of Service (DOS) are identified and correctly entered. |
|
High Claim Billing Lag – Claims take more than ten days to bill from the DOS. |
Implemented a 24-48 hour turnaround time on coding and billing from the DOS to reduce the billing lag to a maximum of three days. |
|
Missed DOS/Appointments – Several DOS/appointments were not billed without a specific reason.. |
Reconcile appointments before billing, summarize the billable appointments, and send routine exceptions to avoid any missed billing. |
|
CPTs Billed With Zero Charge – Many CPTs were billed with a zero charge amount due to incorrect settings in the PMS/EHR/EMR. |
Reconfigure all fee schedules and set standard billed amounts for all CPTs in the system. |
|
CPTs Billed Incorrectly – Many CPTs were billed less than the allowed amount by the payer. |
Establish standard fee schedules as per the provider’s requirement, and set the billed amount as 1.5 times Medicare allowable across the system. |
|
Claims Billed to Wrong Payers – Claims were billed to incorrect payers, such as billing Medicare instead of Medicare HMO or billing secondary instead of primary. |
Implement verification reports to identify the correct payers to bill on DOS. |
| BILLING ERRORS | MEDIENTSKY BILLING ACTIONS |
|---|---|
|
Claims Billed With Missing/Invalid Authorization – Claims were billed without required authorizations or entered with incorrect auth/reference. |
Conducted a post-billing audit to identify any missing or incorrect vital information in the claim. Scrubbing rules in the clearinghouse portal should be implemented to avoid further rejections or denials. |
|
Claims Billed With Missing/Invalid Authorization – Claims were billed without required authorizations or entered with incorrect auth/reference. |
Conducted a post-billing audit to identify any missing or incorrect vital information in the claim. Scrubbing rules in the clearinghouse portal should be implemented to avoid further rejections or denials. |
|
Inaccurate Coding Resulting in Denied or Underpaid Claims – The billing codes for E&M services, testing, and procedures were not coded properly, resulting in claim denials or underpayment. |
Conducted a pre-billing audit of all chart notes, procedure notes, and test results to identify the correct codes in accordance with the provider documentation. |
|
Missing or Incorrect Modifiers – The previous biller failed to include the appropriate modifiers, resulting in claim denials. |
Conducted a coding audit to determine the need for modifiers on E&M codes and distinct procedures and append the correct modifiers for better reimbursement. |
|
Billing Procedures Outside The Global Period – Procedures were billed without checking the global periods. |
Append the correct post-operative modifiers after a consultation or procedure during the post-op period to reduce denials from payers. Claims not covered by post-op coding guidelines are written off with provider approval. |
|
Incorrect or Incomplete Documentation – Incorrect and incomplete chart documentation resulted in a penalty during payer audits. |
Implement streamlined coding and billing practices to meet payer audit requirements. Check provider documentation daily and notify providers of any incomplete, missing, or unsigned notes in the system. |
|
Excessive Units Billed – Billing codes were assigned with incorrect units exceeding the maximum allowable units. |
Conducted a coding audit to identify and correct cases of incorrect units. |
|
Failed to Verify Medical Necessity – ICD/CPT combination codes were used incorrectly, and medical necessity was not checked, resulting in claim denials for incorrect NCD/LCD guidelines. |
After completing a consultation or procedure, use the new method to determine the proper LCD/NCD guidelines for correct billing. |
|
Failed to Follow Payer Guidelines – Coding protocols for specific payers, such as Medicare, Medicaid, and Medicare/Medicaid replacement payers, were not followed. |
Follow the correct coding protocols for each payer to increase reimbursement and reduce denials. |
| ELIGIBILITY ERRORS | MEDIENTSKY BILLING ACTIONS |
|---|---|
|
No Authorization Obtained – Authorization or referrals were not obtained before services were rendered, resulting in many claim denials. |
Conducted pre-verification and authorization processes to request referrals from PCPs in advance. This will allow sufficient time to follow up on the status of authorization or referrals and ensure all necessary information is in place before seeing a patient. |
|
Outdated Authorizations/Referrals – Authorizations or referrals were not correctly updated in the system, resulting in claims being billed with expired authorities. |
Identify expired authorizations/referrals to eliminate claim denials. |
| DENIAL ERRORS | MEDIENTSKY BILLING ACTIONS |
|---|---|
|
Claim Pending Additional Documentation – Claims are being denied/pended for additional documentation without an address, resulting in non-payment. |
Tracked denials and correspondence with denial management within 24-48 hours of receipt to resolve the issue as quickly as possible. |
|
Delay in Receiving ERAs – Claims are being paid on time without obtaining EOBs or ERAs in a timely manner to post the payment in the system. |
Implemented electronic claim and payment transactions to save time and speed up reimbursement. Enroll in EFT/ERA with maximum payers. 95% of payments are now deposited through EFT, and payment explanations are loaded via ERA directly into the system. This ensures payments are posted on time and reduces payment lag. |
| DEEMED AS NON-COLLECTABLE ISSUES | MEDIENTSKY BILLING ACTIONS |
|---|---|
|
Secondary Denied as Primary Paid Max – When a secondary claim is denied because the primary claim has paid more than the allowable amount, any balance should be written off with the provider’s consent. If balances are not addressed, they may sit in the accounts receivable bucket for an extended period, increasing the aging balance. |
Review non-collectible denials on a monthly basis and write off any balances with provider approval. |
|
Non-Covered Charges as per Provider Plan – Claims may be denied as non-covered charges as per the provider contract, and there is no contract with the payer. |
Implemented credentialing and contracting processes with new payers and communicate any non-accepting payers/policies to the front team or patient. Introduce billing reconciliation, pre-verification, authorization, and billing turnaround to reduce TFL and authorization-related claims. |
Phase 3 – Technology and Automation Solutions:
RCM Tools for challenges faced by the Medical Group
The 180 clinic medical group was facing several challenges in their revenue cycle management processes. These included a high number of denied claims, errors in data entry, and time limits for claim submission being exceeded. They were also facing issues with paper documents, and the lack of proper prioritization of their revenue cycle process.
Medientsky Billing’s RCM Tools Solutions
AR Analyzer Tool:
Our AR analyzer software will drastically reduce the rate of bad debt write-offs and create space for their current billing cycle to obtain the correct reimbursement within the normal payment time period which is 7-15 days. The AR analyzer automatically isolated high-risk receivables. It eliminated the need to run multiple reports and a separate view summarizes the entire data. Detailed AR reports that enabled them to manage AR days and AR relationships with payers.
Denial Management Tool
Our Denial management tool tracked dirty or unclean claims at the time of submission using clearinghouse data. It saved time and effort by categorizing denials according to different scenarios, eventually reducing the number of initial payer-end denials. It also helped identify 75% of resolvable denials increasing their collections by $200K
The denial management tool also removed duplicate denials hiding actionable denials. It identifies the last touch or where the account currently sits, so denials such as non-covered charges, service documentation, coding errors, etc. remain hidden under the denial type duplicate denial.
The denial management tool also has an in-built system that alerts users about expiring time limits, helping practices prioritize their denial management. This ensured the 180 clinics’ medical group never miss the deadline to submit claims. It increased their clean claim timely submission by 98% and allowed faster reimbursement resulting in a $150K increase in collections.
Claim Audit Tool
The audit automation application built into the tool analyses payer-specific claims with the amount billed, amount owed, contractual adjustments, and patient responsibility. It provides a turnover report of our overall revenue per time period of our choosing. This helps practices identify discrepancies in their claims and correct them before they become costly errors.
Paper Documents to Electronic Formats
Our paperwork automation tool converted paper documents into electronic formats, reducing the cost by around $5-$8 per claim spent on manual paperwork. This tool allowed paper documents to be converted into 835 or any other data of our choosing. It also allows for the submission of these documents electronically, resulting in quicker payments from insurance carriers.
RCM Workflow Management Tool
The TeamBillingBRidge tool provides protocols for prioritizing the revenue cycle process, focusing on the most deflated areas of the practices’ revenue stream. It offers insights into all areas of RCM, such as claim tracking, reporting, and metrics, providing day-to-day management with a clear picture of the revenue cycle process.
Appeal Automation Tool
Our appeal automation tool used 835 data and segregates denials according to categories. It reduces the need for manual paperwork, saving time and money for healthcare organizations. Along with its 800+ payer appeal and reconsideration forms inbuilt. It pre-populated patient information so that the only work their staff did was to submit the documentation.
Verge of success in collections and streamlined functioning of RCM operations
Our healthcare revenue cycle management and consulting services have a proven track record of success in improving collections and streamlining RCM operations. Some of the key improvement areas we found after streamlining the 180 clinics medical group are:
Enabling patient financial services:
We were initially contracted by the 180 clinics medical group to perform a six-month consulting engagement that involved transitioning our interim VP and using his expertise to successfully transitioned employees to other positions in the organization while liquidating an inventory of patient accounts in excess of $2 million.
Successfully Recovering Aged Accounts Receivables:
Our VP was recommending the 180 clinics medical group based on previous work at another affiliated hospital. the 180 clinics’ medical group consisted of aged accounts. Our AR specialists formed a task force to attack the aged accounts through an approach of working accounts on the client’s host system.After the initial 1 month of the project, collections had increased by 80% over prior internal efforts. After an evaluation of the project’s impact, the scope of work was revised to include accounts assigned at the time of discharge. As a result, cash increased three times higher than the previous levels and resources have been diverted to other areas of the revenue cycle, which has added to the efficiencies of the business office staff.An “audit letter” be implemented in conjunction with a 120-day work plan to accelerate their cash. We converted nearly 20% of the total A/R to cash during the first 30 days of the project. Accounts were re-billed, followed up, and concluded in a timely manner, resulting in an overall reconciliation process that contributed in excess of $ 5,000,000 to the Medical group in 2 months.
Conclusion
The project duration will be for a year. We are hoping to provide more insightful information for the 180 clinics medical group to create a sustainable RCM operation that will support clinical staff such as providers, administrative staff, etc to focus on their main core function which is providing excellent patient care. If you would like to know the progress of this 180 clinic’s medical group keep in touch with our blogs where we will post updated data on the medical group’s improvement over the course of this year.
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Highlights
- Collections had increased by 80%
- Converted nearly 20% of the total A/R to cash
- Reconciliation process that contributed in excess of $500,000
Client Specs
- Location: Washington
- Specialty: Behavioral Health
- EHR: Incredible
- Average collections: 300K per month
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