Revenue Essentials

As physicians take on more extensive roles outside of patient care (e.g., administrative, academic, and billing compliance), involvement in the revenue cycle might diminish or even fail to commence. It is crucial for physicians to keep abreast of revenue cycle issues, but more often than not, they go unnoticed until a physician’s bottom line is affected.

The risk of inappropriately billed claims and corresponding reimbursement is increased until the problem is identified and resolved. In an effort to prevent this from occurring, physicians should get involved with or oversee their billing service or staff. Some of the revenue cycle essentials that require physician attention are:1

  • Periodic reports of claims billed on the physician’s behalf and data regarding payments;
  • Changes in procedure codes, diagnosis codes, or other information furnished by the physician without the physician’s knowledge and consent; and
  • Information received from Medicare and other payors.

FAQ

Q: Should a hospitalist be concerned if the payer determines that they are an outlier of reported physician services?

A: There are several ways a payer can notify a physician that they are an outlier of reported physician services. The first notification could be a simple form letter that summarizes the aberrant billing pattern when compared to physicians of the same specialty. A copy of the associated billing/coding guidelines (e.g., Documentation Guidelines for Evaluation and Management Services) typically is included as a physician reminder. If the outlier pattern continues, the payor can request a sample of submitted physician claims for review. This request can occur before or after payment is received. Post-payment requests might result in refunds, whereas pre-payment requests might result in denied or reduced payments. Physicians whose documentation supports the reported services need not be concerned of the notifications and subsequent requests for documentation. Physicians whose documentation does not support the reported services should seek billing education to improve their coding/billing accuracy.—CP

Feedback

One of the most common billing-related physician complaints involves the lack of feedback. Most physicians want to receive information regarding their quarterly billings: the volume and frequency of specific reported services, and corresponding payments or denials. Physicians prefer to know how they rank as individuals and as a group. Although they might not be experts in coding and documentation, this information offers physicians a feeling of security, as it permits them to identify typical billing patterns or highlight outlier patterns.

Establish communication with the manager/coder/biller to better assist with feedback. Appoint a physician leader to spearhead this effort; ensure feedback is provided quarterly, at a minimum. If the coders/billers feel that they have an approachable contact, they’re more likely to offer feedback before formal reports are generated. A quick resolution of potential problems lessens the financial burden on the HM group, as well as the resource-intensive education process that ensues.

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