Payer Contract Renegotiations: Improving Your Negotiating Skills

Reading Time: 5 minutes

 

Timely and correct reimbursement is always top of mind for a healthcare provider. However, many providers are leaving money on the table due to infrequent payer contract renegotiations.

Due to the nature of payer contracts, which includes fee schedules, reimbursement requirements, as well as conditions payers must meet for timely reimbursement. Therefore, payer contract negotiations are a vital component of a healthy revenue cycle.

Basics of a Payer Contract

Payer contracts are legal documents, and it is essential to have a firm understanding of the fine print. This will help your organization capture all charges and prevent claim denials. It is usual for providers to know the reimbursement rates for their most commonly billed services. However, there are other core elements that they need to be familiar with that can create challenges for revenue cycle management.

Here are eight other critical areas of a payer contract that need to be reviewed and understood:

  • Timely filing: Payers set time limits for filing claims, and your practice must know what those limits are to ensure timely filing. While most practitioners send claims quickly, it is good to understand the time limits for anything that may fall through the cracks.
  • Unilateral Amendments: Every contract has a section pertaining to the process by which a contract can be amended or the ability for the parties to revise the agreement. Some of these contracts allow for changes to be made by the payer without consent from the provider. It would be best if you tried to ensure that the contract can only be amended by mutual agreement, in writing, in advance, and by both parties signing off on the change. Or at least state in the contract that you are to be notified of any revisions before they go into effect and given time to craft a response.
  • Prompt Pay: The contract’s language should be specific regarding the reimbursement practice for all plan products for correctly submitted claims. This should be within 30-45 days of receiving the claim or follow your state’s regulations if there are any.
  • Over/Underpayment: This language refers to the timeframe both parties have for limiting how far back either can go to collect or refund an over or underpayment.
  • Termination: This language is specific to either party’s ability to exit the agreement without cause within a fair amount of time.
  • Assignment/mergers: Any language about assignment or mergers should be reciprocal to the payer and provider. Payers frequently enter into mergers and don’t ask permission from practices. Practices should have the same freedom to conduct business transactions, whether it is a merger or assigning a contract.
  • All Services: This contract language should allow practitioners to provide and be reimbursed for all services that fall within the scope and expertise of their specialty and license so as not to limit them to a specific set of services.
  • Arbitration: The contract should contain appropriate and reasonable arbitration language, ensuring that both parties can access all legal protections. Proper jurisdiction, as well as clear time frames and cost responsibilities, are critical. Also, the contract should be governed by the laws of the state where the practice is located and not the payer’s headquarters.

 

Preparing to Negotiate

You need to make sure you have copies of all contracts to see where you currently are with them and determine where you want or need to go. Have all your contracts in one easy-to-access place; if you can’t find them, request a copy from the payer.

When getting ready to negotiate, you must clearly understand your payer mix. Looking at your entire book of business will help to determine where you are paid the least, the most, and what representation of your patients are under which payers. This will allow you to decide which payers and services to focus on. Other information you need to have to help in your negotiations are details that can help you articulate the story and value of your practice, such as your technology, affiliations, patient population, range of services you offer, what sets your practice apart from your competitors, and the overall goal/purpose of the practice.

Here are five points of negotiation that can help:

  • State laws apply: You should be aware of your state laws and how they affect insurers’ way of conducting business. There may be rules governing timely payment or even takebacks.
  • Be aware of the contract term: Many insurance payers try to get providers to sign long-term contracts, three years or more. If this is the case, does the contract cover built-in increases to keep pace with inflation or other considerations? Usually, they don’t.
  • Make sure rates are transparent: Understand what the rates are based on, whether it be Medicare or a proprietary fee schedule. If Medicare, is it the current or another year? Is there more than one plan under the payer? If so, do you have a fee schedule for all of them?
  • Know the payer: In addition to bringing data from your practice, conduct research to better understand the payor’s specific concerns and areas of focus. For example, if the payor is concerned with minimizing hospitalization rates, bring data to the table showing how your practice has addressed ongoing healthcare, lowering patient hospitalizations.
  • Know your value: Payors respond the best to facts and data. Knowing your worth and quantifying all aspects of your practice can help get you higher reimbursement rates.

You should also develop clear objectives of what your organization expects to gain from the negotiations, whether to increase net yields, boost a specific service line, or enhance payment accountability. But, be prepared for anything by having data-driven, evidence-based responses to potential questions. You can be ready for these by brainstorming with organization stakeholders such as other practitioners, financial leaders, or practice administrators to develop ideas on what the payer may expect from the negotiations and how they may react to your requests, thus putting yourself in a better place to negotiate.

Also, getting input and agreement from key stakeholders can ensure you are flexible where you can be and stand fast on the terms that provide a better outcome for your healthcare organization. You can even determine if there is a point where you are willing to walk away.

Benefits of Negotiating Payer Contracts

It is agreed that contract negotiations can be intimidating, but there are many benefits to be gained by taking the time. Not only does this build relationships with payers, it also can keep the practice top of mind of the payer’s network providers. In addition, it allows practices the opportunity to demonstrate their value to payers while offering clarity on issues within their specialty. In the end, successful negotiations can result in higher reimbursement for services and contract language that protects the business interest of the practice.

Building relationships with payers helps create a strong foundation for negotiations. It is suggested that practices sit down annually with their payer representative to:

  • Introduce practitioners
  • Provide education about the practice’s specialty and value proposition
  • Learn payer’s needs and find opportunities to collaborate

By doing this, you maintain close contact with the payer representative, which can support a mutually positive outcome regarding negotiations.

Getting Help with Your Payer Contract Renegotiations

With all the other things that need to be managed daily, who has the time to establish a comprehensive payer contract management process to handle the complexity of managing multiple contracts. It is hard for a practice to keep up without getting discouraged by the process as it can be lengthy and complicated.

At Billed Right we understand how stressful and time-consuming contract renegotiations can be. Taking the time to review your payer contracts to understand where you currently are can be overwhelming. You also need to analyze your data to determine which payers, plans, and services drive the most value, or the least, consuming even more time and resources. But there is a way to save yourself the time and cost of doing all of this yourself – outsourcing.

Billed Right has a dedicated team of experts who can help prepare and negotiate your payer contracts. In addition, we work closely with you and your team to ensure a solid understanding of your analytical data and what makes your practice unique and work hard to increase reimbursement amounts.

Contact us today to learn more about how we can help you negotiate your payer contracts.

Social Determinants of Health and It’s Utilization in Healthcare

Reading Time: 4 minutes

Utilization of Social Determinants of Health in Healthcare  

Social determinants of health (SDOH) refer to the non-genetic and non-medical conditions in the places people live, learn, work and play that affect health and quality-of-life risks and outcomes. Factors such as economic stability, education, food, housing, transportation, community, and social situations all feed into the social determinants of health. In recent years these have begun to be utilized in promoting health and health equity. It has been determined that a patient’s care journey is 80% dependent on non-clinical factors such as socioeconomic or environmental.   

Our current health system is moving toward a value-based model which incentivizes positive results rather than individualized treatments and procedures. With this shift, healthcare leaders increasingly regard social determinants of health as a critical part of overall healthcare efforts and indicators. By including these facets with standard medical care, providers are taking a holistic view of their patients and enhancing patient care, promoting better outcomes, and driving value.  

There are a growing number of initiatives to address SDOH within healthcare and outside of the healthcare system. Outside, these initiatives aim to shape policies and practices in non-health areas in ways that promote health and health equity. Within the healthcare system, collecting this data can help improve quality and care coordination by identifying social risks and unmet needs such as homelessness or lack of transportation. In addition, they can help to determine healthcare and services follow-up and to plan a patient’s discharge from a hospital situation. Understanding the external factors that can impact a patient’s overall health can also trigger needed referrals to social services that can help meet that individual’s needs.   

Recording Social Determinants of Health 

It has been established that any member of a patient’s care team can collect social determinants of health data during a visit. This includes providers, social workers, community health workers, case managers, and nurses. This data, once gathered, is then recorded in the patient’s health record.   

When ICD-10 codes were first released, they included codes that encompassed SDOH. Some of these “Z” codes are:  

  • Z55 – Education  
  • Z56 – Employment  
  • Z59 – Housing and Economic  
  • Z60 – Social Environment  
  • Z61 – Live Events  
  • Z62 – Upbringing  
  • Z63 – Family and Social Support Issues  
  • Z64 – Certain Psychosocial Circumstances  
  • Z65 – Other Psychosocial Circumstances  

These codes were established to better understand what is happening outside of physical health that can contribute to a patient’s overall well-being. For example, access to public transportation affects a person’s ability to go to work, get healthy food, healthcare, and other important health and wellness factors.   

Z Codes Not Widely Utilized  

According to the American Hospital Association, the Z codes are being utilized infrequently. Reasons range from the codes not being part of reimbursement to not having time to ask the necessary questions during the encounter. As the landscape of healthcare shifts more and more toward value-based care, this information will become extremely important to ensure favorable outcomes in a patient’s overall health.   

Several national initiatives are gaining traction concerning SDOH, including Healthy People 2030 and The Gravity Project. Utilizing these codes can allow for trends to be identified and community-based programs to be started in areas that need social services and prevention programs. And according to the Kaiser Family Foundation’s 50-state Medicaid budget survey, several states require Medicaid MCOs to address social determinants of health as part of their contractual agreement. In addition, in 2018, the CHRONIC Care Act expanded coverage under Medicare Advantage plans to include non-medical interventions. These include transportation to medical appointments, meal delivery, and home improvements that add accessibility, such as installing a wheelchair ramp or handrails.   

Challenges  

It has been acknowledged that one of the most significant challenges related to social determinants of health is the lack of a consistent definition and agreement around what truly is a social determinant. Also cited was the lack of standardization and validated SDOH measures as a major barrier. The concern is around different entities utilizing different methodologies to measure SDOH making comparisons through populations and changes difficult. The thought is that states need to agree on standardizing the various data collection approaches and then incorporating the information into EHRs. Without a uniform reporting and collecting method, the ability of agencies, health plans, and providers to share data and use SDOH to guide their strategies, care planning and make referrals is very limited.   

The other challenge that must be overcome is the lack of interoperability between technology systems like third-party SDOH tools and electronic health records (EHRs).   

Social determinants of health codes can be very powerful tools to collectively measure and evaluate social determinants of health on a national scale. These external factors affecting patients’ health can justify risk adjustment payment methodologies, higher levels of evaluation and management services, prolonged services, extended monitoring, etc. Utilizing these codes can greatly impact public health issues if providers and coders embrace the importance of including these in their comprehensive clinical documentation.   

_________________________________________________________________________________  

Who is Billed Right?  

In 2006, two business partners envisioned creating holistic services that help improve medical billing operations. They started by listening to doctors and building a service model around what doctors need the most. As a result, Billed Right’s Revenue Cycle Management (RCM) model was born. The focus continues to be on solving the problem rather than selling a product. Hence, Billed Right’s advanced RCM model revolves around personalized service in today’s corporate world while still cutting costs and improving patient care and practice revenue. As a strategic partner, we look to streamline your revenue cycle and operational management, thus helping you to grow your healthcare practice.  

  

Contact Billed Right to learn more.   

OIG Exclusion List – What Is It and How Can It Affect Your Practice?  

Reading Time: 4 minutes

There are many rules and regulations around accepting Medicare, Medicaid, and other federal healthcare programs. And if you are a practice that accepts and bills for these federal government programs, it is your responsibility to ensure you are protecting patients from things such as fraud and abuse. To that end, you need to know the exemption status of all employees, contractors, and vendors. Not knowing and having someone on staff, or utilizing an excluded vendor, can lead to significant consequences such as substantial fines and loss of your ability to participate in Medicare and Medicaid.  

What is an Exclusion?  

An exclusion is an extreme civil sanction imposed on individuals or entities by the Department of Health and Human Services, Office of the Inspector General (OIG). This occurs when a healthcare provider or vendor is convicted of a crime such as fraud or theft, license revocation, or has engaged in professional misconduct, abuse, or neglect. These individuals are then excluded from working with or for a healthcare program that is federally funded.   

There are two types of exclusions on the OIG list and multiple ways you can end up on it:  

Mandatory Exclusions: (minimum of five years, can be longer or indefinite)   

  • Felony conviction of Medicaid or Medicare fraud  
  • Felony conviction of substance abuse, including alcohol  
  • Patient abuse or neglect  
  • Felony conviction for other healthcare-related fraud, theft, or other financial misconduct  
  • Felony conviction that relates to the unlawful manufacturing, distributing, prescribing, or dispensing of controlled substances, and more  

Permissive Exclusions: (this is discretionary and can be for up to 5 years, but usually 1-3)  

  • Misdemeanor convictions related to healthcare fraud  
  • Misdemeanor conviction of substance abuse, including alcohol  
  • Misdemeanor convictions relating to the unlawful manufacturing, distributing, prescribing, or dispensing of controlled substances  
  • Default on a federal student loan  
  • Submission of false or fraudulent claims to a federal health care program and more  

Getting Removed from the List  

A provider or entity on the exclusion list can get removed once the exclusion period has expired, but they have to apply for reinstatement. It is not automatic. To start the reinstatement process, you must fax or email the request to OIG with the following information included with the request for removal from the exclusion list:  

  • Individual’s or entity’s full name (which the exclusion is under)  
  • Date of birth for an individual  
  • Telephone number  
  • Email address  
  • Mailing address  

If eligible, the OIG will send the statement and authorization forms to be filled out and returned. Once they have reviewed the completed forms, the OIG will send a written notice of reinstatement or denial. This isn’t a quick process and can take up to 120 days or more to complete.  

How to Ensure You Are Compliant  

Even if unintentional, a mistake can get you into serious trouble with the OIG. Sanctions for violations can reach as high as $10,000 per service item claimed and an assessment of up to three times the amount claimed for each service or item, meaning the penalties can add up quickly and run into the hundreds of thousands of dollars. In addition to financial liability, you can end up on the list yourself and lose your ability to bill any federally funded healthcare program such as Medicaid and Medicare.    

But there is help! The OIG provides a resource that can help you avoid exclusion errors and keep you in good standing with Medicare and Medicaid, avoiding expensive penalties. The resource available is called the List of Excluded Individuals and Entities (LEIE) and is updated when individuals or vendors are excluded from being able to bill Medicare or Medicaid.   

Using the LEIE list can help keep you from accidentally contracting with a vendor or hiring an employee who has been designated excluded from billing with federal government programs. Without this list, your practice could have significant enforcement actions against it. Or worse, you could end up on the exclusion list yourself and unable to see, or bill for, patients on Medicare, Medicaid, or other government programs.  

Utilizing Exclusion Lists  

Checking the OIG LEIE list regularly can help to alleviate situations where you hire or contract with someone on the list. The database includes over 60,000 people, vendors, and entities excluded from federal government healthcare programs and is updated monthly. You can search online, or there is a downloadable database. However, the download doesn’t include Social Security numbers or EINs. Therefore, you have to search online to be sure the person you found on the list is the correct one.   

In addition to the LEIE list, if you get reimbursed with federal program dollars and require Government Services Administration approval, you must also check SAM.gov Excluded Parties List System. The people and entities on this list have been debarred, sanctioned, or otherwise excluded from doing business under a federal contract.   

What To Do If You Make a Mistake?   

Situations happen, and should you find an individual or entity on the list with whom you are doing business or are looking to do business, you must take immediate action. The action necessary will depend on the situation:  

Pre-Employment Check: Should you run a check on a potential new hire and they are found on the list, the action is simple – don’t hire them. This does not apply to patient-facing employees such as nurses or doctors but to all employees or vendors that may provide support services and administrative and managerial positions.   

Existing Employee/Vendor: After you have hired or contracted with someone and their name appears on the exclusion list, it isn’t as easy, but there are actions to take to lessen the repercussions. Self-disclosure is the process that will allow your practice to avoid costs or disruptions that could be associated with government-directed investigations or civil or administrative litigation. The downside is that you may still face penalties; however, reporting the situation yourself is much less damaging than if OIG figures it out first.   

Conclusion  

It is your responsibility to ensure that you are not hiring or contracting with anyone who is considered excluded from billing federal government programs such as Medicare or Medicaid. A reminder to regularly check LEIE and SAM.gov can help your practice stay compliant.   

__________________________________________________________________________________  

Who is Billed Right?  

In 2006, two business partners envisioned creating holistic services that can help improve medical billing operations. They started by listening to doctors and building a service model around what doctors need the most. As a result, Billed Right’s Revenue Cycle Management (RCM) model was born. The focus continues to be on solving the problem rather than selling a product. Hence, Billed Right’s advanced RCM model revolves around personalized service in today’s corporate world, while still cutting costs and improving both patient care and practice revenue. No matter what challenges physicians face, we never waiver from our goal to be a strategic partner and promote practice growth.   

  

Contact Billed Right to learn more.   

 

 

Medical Staffing Shortages Continue Into 2023

Reading Time: 3 minutes

The pandemic has been blamed for many of the problems happening in the world; however, it didn’t cause the shortage of healthcare workers. It did, however, compound it in a big way. It is estimated that nearly one in five healthcare workers has resigned since March 2020.   

Not only is there a severe shortage of nurses and medical assistants, but there is also a shortage of case managers, administrative support, and medical billing staff. As a result, providers are finding it hard to run their practices due to the lack of administrative help. In addition, the shortage of clerical and administrative staff has also resulted in longer wait times for referrals, prior authorizations, or even getting phones answered. More importantly, overall short staffing is causing treatment delays, misdiagnoses, and unintentional medical errors as the existing workforce attempts to manage the same workload with less support.    

In an MGMA poll from last September, 73% of medical group practices responded that staffing was the leading COVID-19 challenge going into 2022. Unfortunately, the shortage of healthcare workers is expected to continue to be an ongoing challenge for organizations as the strained workforce changes jobs for better pay and benefits, even going as far as to leave the healthcare industry altogether. A poll in February revealed that almost half of the respondents said that staff turnover rates worsened in the past quarter (41%) compared to 33% who noted it was about the same as previous quarters and 26% who said turnover had slowed recently.   

And in April, MGMA sent out another poll asking medical practice leaders what their best tactic was to address staffing in 2022. Again, the majority reported “raise wages” at 56%, followed by “flexible schedules” at 29%, 10% stated “other,” and 5% said “temp workers.”  

Of the respondents that stated “other,” here are some of the tactics that were included:  

  • Improve employee engagement efforts   
  • Improved benefits such as more time off and reduced schedules  
  • Adding referral bonuses for existing staff who bring in new hires  
  • Increasing automation of administrative tasks and use of bots  
  • Outsourcing for scribe work and medical coding  
  • Providing pre-emptive salary increases ahead of schedule  

Impact on Patients  

Not surprisingly, the healthcare staffing shortage is being felt by patients. Based on a CVS Health-Harris Poll National Health project, more than half of all Americans say they have directly felt the effects. From canceled appointments to delayed surgeries, shortened office hours due to lack of staff, to people stating their practitioner has stopped practicing medicine completely. By mid-2021, over 41% of adults in the United States decided to avoid or delay medical care due to COVID-19. And now, those adults are starting to reconnect with their providers and reassess their care after the pandemic lockdowns and restrictions. When providers need the income to help recover from the pandemic, a shortage of employees leaves them still losing revenue due to a lack of support staff and clinicians, lessening the number of patients they can see daily.   

Outsourcing  

One of the biggest opportunities to shore up your workforce, streamline workflows and save time and money is to contract out or outsource administrative tasks that are difficult or expensive to staff internally. These can include:  

MGMA did a poll in March 2022 asking medical practices they will be outsourcing/automating in the next six months. Of those polled, 36% stated “revenue cycle,” 33% said “patient communication,” 9% said “clinical efficiency,” and 23% said “other,” which included things like medical billing, call center, and IT services. This poll shows that the medical worker shortage is forcing medical practice leaders to think outside the box on ways to streamline workflows and ensure they have the right workers for all the key roles in their practice.   

How Billed Right Can Help   

We understand how hard it can be to decide to outsource your medical billing. But partnering with a company that understands the importance of revenue cycle management can help ensure the financial health of your practice. Billed Right handles everything from eligibility verification to claim denial management to Account Receivable collections. As a strategic partner, we look to streamline your revenue cycle and operational management, thus helping you to increase revenue and grow your healthcare practice.  

In addition to being a revenue cycle management company, we also offer front, mid and back-office services such as credentialing, fax sorting, and a virtual medical receptionist who can allow you to take even more of the administrative burden off your existing staff. By outsourcing these functions, you further streamline your workflow and allow your in-house staff the ability to focus on providing quality patient care.   

Contact us today to learn more about how we can help support your practice by becoming a strategic partner.  

 

 

Patient Access to Their Records is the Law

Reading Time: 3 minutes

We have all heard of HIPAA, and most of us associate it with the safekeeping of personal health information collected by providers, healthcare practices, and facilities. However, the HIPAA Privacy Rule also mandates that you provide adequate access to patients to information found in “a designated record set” or their medical records. The rule allows patients to request copies of their records in several formats, including electronic, via a secure web portal, or as a printed copy, and federal law requires you to comply. This means, for example, that if a patient requests an electronic copy of a paper record, the provider is required to scan the paper information into an electronic format. Patient Access to Their Records is the Law

Right of Access to Patient Records

HIPAA governs the right of access rule and, recently, has been more clearly defined by the 21st Century Cures Act. The right of access rule under HIPAA allows patients to inspect and obtain copies of their health records from their providers. This means that as their provider, you are required to allow patients to either view or obtain copies of their protected health information in the manner they choose.   

The 21st Century Cures Act, although signed into law several years ago, has only recently gone into effect. Part of this Act deals with the designation of the Office of the National Coordinator for Health Information Technology (ONC) utilizing electronic health records to improve patient care. After that, the ONC adopted a Final Rule targeting the support of seamless and secure access, exchange, and use of electronic health information.   

The rule, known as the “information blocking” rule, changes the way you respond to requests for patient records. It calls on the healthcare industry to adopt standardized application programming interfaces (APIs), helping to allow patients to securely and easily access their electronic health information from certified EHR systems via smartphones, tablets, or computers. In addition, the rule requires that healthcare providers give patients access, without charge, to all the information in their electronic medical records “without delay.”    

Understanding all the ins and outs of correctly providing adequate access to personal health records can be frustrating, but there are a few key things to remember.  

Types of clinical notes that are required to be made available:  

  • Consultation notes  
  • Discharge summary notes  
  • Procedure notes  
  • Progress notes  
  • History and physical  
  • Imaging narratives  
  • Lab reports  
  • Pathology reports  

 

Information that is not required to be made available:  

  • Any information not utilized to make decisions  
  • Psychotherapy notes such as those recorded during personal therapy sessions  
  • Any information being collected in reasonable anticipation of a civil, criminal, or administrative action or court proceeding  

Patients may not always have access to the ability to view their records electronically and can request paper copies of their medical records. If you receive a request for paper copies, you must provide them within 30 days. However, a 30-day extension is allowed for specific situations, such as needing to pull records from storage. Also, you may be able to charge a reasonable fee to cover the costs of making the copies, such as for labor or supplies. Remember that some states have specific laws related to what can be charged for supplying medical records, so be sure you verify your state law before charging anything.

The bottom line is that you cannot refuse to provide access to a patient requesting their medical records, even if they cannot afford to pay the standard fee you charge, as it can quickly lead to a HIPAA complaint, audit, violation, and big fines.

 

 

__________________________________________________________________________________ 

Who is Billed Right?  

In 2006, two business partners envisioned creating holistic services that help improve medical billing operations. They started by listening to doctors and building a service model around what doctors need the most. As a result, Billed Right’s Revenue Cycle Management (RCM) model was born. The focus continues to be on solving the problem rather than selling a product. Hence, Billed Right’s advanced RCM model revolves around personalized service in today’s corporate world while still cutting costs and improving patient care and practice revenue. As a strategic partner, we look to streamline your revenue cycle and operational management, thus helping you to grow your healthcare practice.  

  

Contact Billed Right to learn more. 

Orlando-based Revenue Cycle Management Company Billed Right Acquires Miami-based Medical Billing Company Ruffe Systems, Inc. (RSI).

Reading Time: 2 minutes

Orlando, Florida, April 26, 2022 – Billed Right, a nationwide Revenue Cycle Management company founded in 2006, headquartered in Longwood, Florida, announced today the acquisition of Miami-based medical billing company RSI.

“We are thrilled to add RSI to our Billed Right family as we are both driven by the same values of building long-term partnerships, focusing on people, and promoting honesty and trustworthy practices in the services we offer to healthcare organizations. We are driven by our core values and always strive to find and maintain alignment between us, our team, clients, and partnerships; this acquisition is no exception. For over 30 years, RSI. has demonstrated success in providing significant value for practices across several specialties with their expertise and innovation and we are thrilled to have them join forces with Billed Right.” said Saurin Patel, CEO of Billed Right.

This acquisition will complement the experience Billed Right gained over the last 16 years in the medical billing industry for a multitude of medical specialties such as Cardiology, Primary Care, Internal Medicine, Psychiatry, Urgent Care, Pain Management, and many more. It also allows Billed Right to expand its presence to South Florida.

Established in 1982, RSI has consistently delivered services beyond medical billing. RSI specializes in medical billing services for hospital-based physician groups such as pathology and radiology. Ruffe Systems, Inc. was originally created through the collaborative vision of radiologists and a specialized medical software developer. RSI has innovative, best-in-class technology for the specialized needs of physicians’ billing and revenue collection. With Integrity as a core RSI value, it allowed them to deliver revenue success to providers for over 30 years.

With the Global Medical Billing, Outsourcing Market Size projected to register a CAGR increase of 12.6% during the 2021 – 2027 time period, it only makes sense that Billed Right position itself to increase its ability to service more healthcare organizations in different geographical areas. This acquisition will add a second Florida location to Billed Right’s portfolio and will allow them to continue growing their reach in the Florida medical billing market and beyond.

About Billed Right:

Billed Right is a Florida-based company providing leading and innovative expertise in revenue cycle management solutions while building meaningful partnerships with our clients. Guided by our mission, we empower doctors to focus on delivering the best patient care. Driven by our vision, we focus on leading in revenue cycle and operational management for healthcare organizations of all specialties. As a company, we take pride in delivering experience and unsurpassed business solutions to meet and enhance the needs of our healthcare providers.  Website: www.billedright.com

About Ruffe Systems, Inc.

Ruffe Systems Inc. is a medical billing company based out of Miami, Florida. They provide complete billing services for hospital-based physician groups throughout Florida. They specialize in Pathology, Radiology, Cardiology, Emergency, and Urgent Care billing. RSI was founded in 1982.

10 Questions to Ask When Hiring a Medical Billing Company

Reading Time: 3 minutes

The healthcare landscape has changed considerably over the last couple of years thanks to COVID-19. Whether your practice lost revenue due to a reduction of in-person visits, you are struggling with the Great Resignation situation or both. Your goal at this point is to figure out how to lessen expenses, increase staff, and maintain a positive cash flow.

But how do you decrease your expenses and add important staff to your team, all while increasing your revenue? Hiring an experienced medical billing company could be the answer you are looking for. But you don’t want to just hire anyone. You need to be sure that the medical billing company you hire has the knowledge and expertise that can not only help you manage your medical billing but also help grow your practice.

To ensure you are hiring the right medical billing company there are several questions that you should ask when making this critical decision:

  1. How long has the company been in business? You need to understand how long the company has been handling medical billing. As part of this line of inquiry, also ask what their customer retention rate is and the average length of time they have had their clients?
  2. What will it cost? This of course is top of everyone’s mind when looking to outsource. Standard in the industry is a percentage of net revenue collected, normally under 8%. Also ask about any start-up fees, data conversion fees, termination fees, and any other surprise or hidden additional costs.
  3. Have they worked with practices of similar size, scope, and/or specialty as yours? Verifying that the company understands your specific needs is important. You could even ask if they have testimonials or references you could speak to.
  4. What exactly are the services they offer? Do they only do medical billing or are they a true revenue cycle management company that does everything from eligibility verification through collecting on account receivables? Are there services they don’t provide in their rate? Some companies charge extra for patient collection follow-up and other services. Also, do they work in your EHR or will you have to change software?
  5. Will you have access to all the billing information? Your billing information is just that, yours, and you should be able to access it at any time, for any reason.
  6. Are they HIPAA compliant? Protecting patient data is a top priority. Do they ensure compliance with stringent software and encryption practices that minimize the risk of patient data loss?
  7. Do they provide transparency into their performance? Do they provide reports? If so, what are they and how often will you receive them? Can they customize reports based on your needs? How will they communicate with you through the process? What will your responsibilities in the medical billing process be?
  8. What kind of training do their employees receive? Are their coders certified? What kind of training do they get to continually keep up with rules and guidelines? Are they utilizing the most recent guidebooks and resources, for example, CPT, ICD-10, HCPCS?
  9. How are denied claims handled? Although hiring a medical billing company should lessen the number of denied claims due to their expertise, denials will happen. How do they handle them?
  10. What happens when the people on my account get sick or go on vacation? You need to make sure that you will receive the same level of service every day, even if the people who usually work on your account are out. Do they have a team that is cross-trained and can ensure a consistent service level?

 

With the answers to these questions in hand, you will be more prepared to choose the best medical billing company for your healthcare practice.

Who is Billed Right and How Can They Help with Your Medical Billing?

Founded in 2006, Billed Right is a Florida-based company providing leading and innovative expertise in revenue cycle management solutions while building meaningful partnerships with our clients. Guided by our mission, we empower doctors to focus on delivering the best patient care. Driven by our vision, we focus on leading in revenue cycle and operational management for healthcare organizations of all specialties. As a company, we take pride in delivering experience and unsurpassed business solutions to meet and enhance the needs of our healthcare providers.

Contact Billed Right to schedule a consultation and learn more about how becoming a strategic partner with us can benefit your practice.

 

Correctly Handling Medical Balance Write-offs

Reading Time: 3 minutes

You and your staff work hard taking care of patients and deserve to be compensated for your efforts. With third-party payers, uninsured patients, or ones with high deductible insurance, there are unfortunately times when you have to write off some, or all of the charges, for a visit. Medical billing is complicated enough without adding this to the mix, but it is a fact of doing business. It takes well-trained revenue cycle management staff and clear, consistent billing policies and procedures to handle all your billing challenges.

Standard or Expected Write-offs

There can be a number of reasons for write-offs, some of them are approved and even expected, such as the following:

  • Contractual write-offs are the difference between the set fee from the practice fee schedule and the allowable fee schedule the practice has agreed to accept. An example of such an agreement is the one made between a practitioner and an insurance company.
  • Hardship or Charity write-offs happen when a patient is having a hard time financially and is incapable of paying. These write-offs can be due to policy adherence in a faith-based health care system, as part of a community indigent care effort, or a financial assistance program. Documentation of the patient financial hardship and a qualification process must be in place before considering this write-off.
  • Self-pay (no insurance) discounts happen when the patient receives a discount off the set fee schedule for paying their balance in full at the time of service because they are uninsured.

Unexpected or Unnecessary Write-offs

All of the reasons above are standard write-off reasons, however, some situations can happen that are not expected and can get you into trouble either financially, legally, or both, if not handled correctly.

  • Errors in medical claims such as coding issues, documentation issues, or erroneous patient information lead to denials. Once this occurs your staff needs to be able to immediately make corrections and appeal the medical claim denial. If it isn’t appealed promptly the revenue is lost.
  • Missing medical claim filing deadlines for a payer. Each payer has a contracted deadline for filing medical claims and if this is missed you don’t get paid. Each payer is different so ensure you know each payer’s deadline.
  • Un-credentialed provider write-offs happen when you file a claim for a practitioner who has not finalized their credentialing and contracting with payers prior to the filing.
  • Waiving or writing off copays or deductibles by writing these balances off you could be violating regulations including the Anti-kickback Statute, the False Claims Act, the Civil Monetary Penalties Law, and/or some state laws and regulations.
  • Payer Changes happen when a payer makes changes without notifying a practice.
  • Bad debt write-off is debt that, after exhausting all avenues to collect, you decide to write off the debt for good.

Suggestions for Managing Write-offs

To ensure you are managing your write-offs it is suggested that you start with basic write-off categories and add more as needed. Also, decide which write-offs need manager approval. Although not all write-offs should require approval, as this can complicate the process more, there are times when it is prudent to get an approval.

It is also advised that you do write-offs monthly and track them to see if you spot any trends.  But remember, if you raise your fees but don’t renegotiate your contracts with payers, your contractual write-offs will start trending higher. Also, keep in mind that sending a balance to collections is not the same as writing off a debt. The monies owed are not forgiven but transferred to a third party to collect for you.

And it is a good idea to audit your write-offs periodically to ensure they are being handled correctly. Knowing they are being checked can keep your staff vigilant and you will know you are making business decisions on accurate information.  Overall, try to keep your write-offs to a minimum.

Ensuring the financial health of your practice is a priority and being in control of the unnecessary write-offs can help to support a healthy financial situation.

_________________________________________________________________________________

Who is Billed Right?

In 2006, two business partners had a vision of creating holistic services that help improve medical billing operations. They started by listening to doctors and building a service model around what doctors need the most. As a result, Billed Right’s Revenue Cycle Management (RCM) model was born. The focus continues to be on solving the problem, rather than selling a product, and hence, Billed Right’s advanced RCM model revolves around personalized service in today’s corporate world, while still cutting costs and improving both patient care and practice revenue.  As a strategic partner, we look to streamline your revenue cycle and operational management thus helping you to grow your healthcare practice.

 

Contact Billed Right to learn more about how we can become your strategic partner.

MGMA Poll Shows Need for Prior Authorizations Continues to Increase

Reading Time: 3 minutes

A recent poll by MGMA showed that 79% of those polled indicated that prior authorizations (PA) requirements had increased when asked “How did payer prior authorization requirements change in the past 12 months?”. Only 19% said they stayed the same and 2% stated they had decreased.

They also noted significant challenges associated with the increase in PA requirements:

  • Slow or lack of response from payers on approvals
  • An increase in time spent by staff to obtain PAs, which has been compounded by the shortage in staff amid the tightened labor market
  • Patient care delays due to lack of PAs

A study, by the AMA, showed that 88% of physicians responded that handling PA requests are either a “high” or an “extremely high” burden on them and their staff. Over 90% of respondents stated that PA requests “often”, “always”, or “sometimes” hold up patient care. The survey also found that an average of 13 hours a week are spent by medical staff completing PA requirements for medications, medical services, and procedures that are needed. That is the equivalent of almost two days per week spent obtaining prior authorizations.

Patient Care Suffers

A concerning downside to the increase of prior authorizations has to do with actual patient care. When asked, 29% of physicians said they waited at least three business days to receive a response from the payer, and 64% said they waited one business day. A number of physicians have reported that prior authorizations have led to adverse patient events due to not receiving a PA promptly. Or patients have abandoned treatment completely due to the time-consuming nature of prior authorizations and not being able to move ahead with treatment immediately.

Insurance Companies Keeping Costs In Line

It is understood that insurance companies want to keep costs in line. Prior authorizations are their way to control costs by determining if a procedure or medication is medically necessary, being duplicated, if there is a less expensive option, or if it is even covered under the patient’s insurance plan. However, prior authorizations take a lot of administrative time to procure. There are forms to complete and sometimes follow-up calls or faxes that need to happen. All to ensure that the PA is received promptly to minimize any delay in medical care and avoid a medical claim denial.

How to Reduce the Stress

In an effort to streamline the process for your practice, without taking on the burden of another employee, which includes salary, benefits, training, and unfortunately, turnover, outsourcing this function can be the answer. Hiring a company that specializes in obtaining prior authorizations can save you time and increase revenue. Easing the stress on you and your office staff and allowing the focus to return to providing your patients the quality care they deserve.

How Billed Right Can Help with Prior Authorizations

At Billed Right, we specialize in revenue cycle and operational management, including offering a prior authorization service as an add-on solution. We can provide you with peace of mind that your PAs are being requested, followed up on, and filed appropriately in your EHR software. This helps avoid medical claim denials, patient frustration, and loss of staff time.

Our team of experts understands all the ins and outs of obtaining prior authorizations and submit authorization requests within 12 – 24 hours, follow-up with payers ensuring that they are received quickly, and work within your EHR so that your staff has access to them when they are needed.

We are more than a vendor, we are a strategic partner, working hard to support your practice’s growth.

Contact us today to learn more about how we can help by handling your prior authorizations!

Research Shows the Outsourcing Medical Billing Market Will Increase

Reading Time: 3 minutes

According to the Global Medical Billing Outsourcing Market Size study, the global medical billing outsourcing market was worth US$10.2 billion in 2020 and is projected to register a compound annual growth rate (CAGR) of 12.6% during 2021-2027.

Some of the driving forces behind this projected growth come from the pandemic and private physicians needing to trim their budgets and generate more income.  The industry was struck hard when the ability to see patients in person was derailed by COVID 19 and fear of being exposed to the virus kept patients home. The drop in some physicians’ revenue, according to research, was as much as 50%, but on average was about 30-35%. Physicians will be looking to save on overhead costs and make up some of their lost revenue by outsourcing their medical billing.

Another reason is the shortage of healthcare workers. The pandemic has seen an unprecedented reduction in workers while seeing an increase in the need for medical care, both due to COVID infections and in the specialty area of mental health.  For example, the two states most impacted by the pandemic are New York and California. These states may see their labor forces drop by as much as 500,000 by 2026. However, patient visits are estimated to increase by another 10% by 2026. Outsourcing will be a way to eliminate the void left by the staffing shortage and keep cash flowing into practices.

Medical billing is an important part of the health of a medical practice and ensuring that it is executed successfully is critical. Although it may seem counter-intuitive, outsourcing medical billing can be the answer. Looking at the overall cost of salaries, benefits, and continually training staff to keep up with this complex job, having an outside company that focuses solely on medical billing can actually save you money. It can also give your office staff back critical time, allowing them the ability to provide a good patient experience. Not having to be divided between following up with payers on medical claims and handling patients can increase the happiness of not only your patients but your workers as well.

Here is a list of benefits that can come from outsourcing your medical billing.

  1. Reduces Billing Errors. A medical billing company’s sole responsibility is to ensure they provide exceptional medical billing services. Which means staying compliant and up to date on the most current medical codes and payer guidelines. This helps to reduce the number of denials and rejected claims due to billing errors. They can also provide feedback to help maximize income from future claims.
  2. Improves Cash Flow. Most practices have only a few people that handle their medical billing, some only have one. What happens when your biller goes on vacation, gets sick, or worse leaves? Medical claims have to wait and cash flow slows down. By outsourcing to a medical billing services company you never have to worry about that as they have teams dedicated to ensuring your claims go out promptly.
  3. Ensures Billing Compliance. We all know that healthcare is an ever-changing industry. Keeping up with Medicaid, Medicare and private payers is what makes billing complex and hard to stay on top of. Since all medical billing service companies do is focus on the billing cycle they have to stay up-to-date on the latest in government regulations and private payer guidelines in order to maintain compliance and the submission of clean claims.
  4. Increases Revenue. Understanding that by outsourcing your billing you can save money on overhead expenses such as salaries, benefits, training, office space, and supplies, you can see how there would be an increase in revenue. Also, outsourced medical billing service companies can help you clarify your medical claims to ensure you are obtaining the most reimbursement for your patient care. This is done by reviewing documentation and pointing out modifiers that should be listed based on the notes. And by getting clean claims out on time, you will also see an increase in revenue due to fewer claim denials.
  5. Improves Patient Satisfaction. Having to handle both billing paperwork and face–to–face patient interaction can be challenging at the best of times. Reducing the stress on your staff by removing the burden of medical billing frees them up to provide exceptional customer service and focus on what is important – the patient’s experience.

How Outsourcing Your Medical Billing Can Impact Your Bottom line?

We understand that the decision of hiring a medical billing company requires a great deal of thought. We also know that outsourcing can positively impact your bottom line if you partner with the right company. You can lower your overhead expenses and increase your cash flow. With an entire medical billing team focused on your revenue cycle management, your internal staff can focus on providing quality patient care.

Let Billed Right become your strategic partner. With over 15 years of experience handling a variety of medical specialties, we understand all the pain points and how to eliminate them from your daily workflow.  From understanding claim profitability, navigating complex payor rules, keeping up-to-date on everchanging reimbursement methodologies, and analyzing denial trends impacting your practice, we partner with you to navigate all the facets of the revenue cycle.

Contact Billed Right today to learn how we can be your strategic partner and not only increase your revenue but grow your practice.