How to optimize revenue in wound care?

 

A Chinese philosopher, Lao-Tzu, is given credit for the quote ‘A journey of 1000 miles begins with a single step’, or simply put, a change in revenue optimization begins with you—the single step—accepting that the status quo must go. Before learning more about ways to increase wound care revenue let us first take a brief look at insurance systems and payments in America.

Basic overview of insurance systems and payments in America

In general, medical/health insurance coverage is provided by insurance providers such as Humana, United Healthcare and Aetna. Individuals aged 65 years and older have their health insurance covered by the Centers for Medicare and Medicaid Services (CMS) through Medicare. Medicaid helps with medical costs for some people with limited income. There are Medicare Administrative Contractors (MACs) that process claims for Medicare Part A, Part B, Home Health and Hospice and Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) claims. Most CMS wound care claims will be processed by a Part A/B or DME MAC.

Understanding payer requirements is the key to enhancing revenue. If they are not known/met you are significantly increasing the chance the claim will be rejected (have an administrative or clinical error) or denied (deemed unpayable), resulting in extra office processing costs of $25–65 or more per claim. Wound care revenue optimisation involves understanding ‘write-offs’. If you accept assignment, the difference between the billed and allowed amount is the write-off. Write-offs that physicians, especially those in private practice, need to focus on are those due to patients not paying, as well as write-offs due to a denied or rejected claim not being reprocessed, as these are draining revenue from the practice and reflect revenue the office can control.

Optimizing revenue through understanding insurance payer requirements

To maximize the posting of revenue it is important to understand that the main steps of revenue cycle management (RCM) include scheduling, staff responsibilities, medical record documentation, charge capture, coding, charge entry, claims transmission, payment posting, denial management and working accounts receivable.

Clinical tasks associated with understanding payer requirements and maximizing revenue consist of staff responsibilities and medical record documentation. Tasks performed by the clinical team should be done by the most junior member who has the training/qualifications to perform the task.

Revenue, as well as your time, can be optimized by understanding payer medical necessity/clinical requirements for the test, procedure, service or care you feel the patient needs. Fortunately, major insurance payers have medical necessity and clinical documentation requirements available to you. This information is to be found on the payer websites under names such as clinical policies or clinical bulletins. The CMS is divided into regions that process claims through a MAC. CMS medical necessity and clinical requirements are either National Coverage Determinations (NCDs) that apply to all states and territories covered by CMS or through Local Coverage Determinations (LCDs) which apply only to the states or territories that are covered by that MAC.

Some means of maximizing revenue through key administrative strategies include:

• Staff responsibilities: performing 100% patient eligibility checks
• Charge capture: ensuring every test, service or procedure that is rendered is documented and that the charge capture sheet is current
• Coding: having a backup plan in place so when primary coder(s) are absent, coding can still be done without delaying the generation of revenue
• Charge entry: services rendered need to be input on the claim’s forms with minimal delay, within 24 hours of receipt
• Claims transmission: electronic claims should be sent multiple times throughout the day and paper claims need to be sent daily
• Payment posting should include the processing of all payments within 24 hours of receipt
• Denial management: promptly distributing for rework all rejected/denied claims, as well as those that were underpayments
• Working accounts receivable: verifying claims were received, checking on the status of claims (within two days of the date that the claim should have been processed).

Aligning office processes to meet payer requirements

The best way to determine where revenue is being lost, excluding write-offs, is for the office manager, billing manger or your billing service to generate a report indicating what services result in a high volume of claim rejections or are denied. If you outsource billing services and your office is not capable of generating current claim status reports without help from the outsourced billing provider, there is a lack of transparency and a new billing service needs to be used, as you have limited control over the financial status of services the office has provided to patients. Based on the reports, you might focus on high-value services, lower-value services that have a high percentage of claims rejected/denied or you might just start with addressing the insurance payer that results in the most revenue being rejected/denied.

The office needs to be proactive so they can meet or support payer requirements. You know where medical necessity and clinical requirements can be found, but do the physician/clinical staff have a template or checklist that will help them to obtain and document that critical information? Within 48 hours of the appointment being made, does the physician briefly look at the reason for visit and indicate test, procedures, and services the patient will likely need? If so, administrative staff can begin work on obtaining prior certification. Start by maybe doing this with five established patients a day with a goal of doing this for all patients.

Information in this article provides a high-level look at how a medical practice can increase its revenue. First, it takes someone to recognize the need for change, do 100% eligibility checks every day, focus on meeting insurance payer requirements, and finally use office processes that support these requirements.

Reference : Journal of Wound Care