Medical practices can measure success in many different ways. When it comes to revenue, an upward trend is definitely a positive thing. There are actions a practice can take to ensure they don't see their revenue plummeting towards the point of no return. Here are 3 proactive approaches to increasing your medical practice revenue.
Medical credentialing is a crucial process in relation to the claim life cycle, but why? Credentialing is the first step in establishing a contract with the payer. By enrolling as an in-network provider, you can now leverage your agreements with the payer to ensure that you are reimbursed for your services and at the proper contractual rate. Without it, your practice risks losing thousands to hundreds of thousands of dollars in revenue per year as a result of denied claims or delays in adjudication. If you neglect your credentialing or make the slightest mistake on your application, you chance your enrollment being rejected and the consequences will be as severe as non-payment for your services.
Credentialing also opens up more opportunities for providers to expand their patient base. When credentialing with a payer, you’ll enroll with their networks, increasing the number of patients that now can be seen by your practice as “in-network.” This can have a direct impact on the number of referrals that you receive, which ultimately increases your revenue stream. Patients are more inclined to be treated by an in-network provider since it’s more cost-effective with less out-of-pocket expenses for the patient. The comfort of knowing that this provider has been vetted by the payer is also a factor that a patient takes into consideration when selecting a physician.
You can begin by evaluating your local payers to determine which are worth pursuing contracts with. Although carriers will not disclose their fee schedule upfront, you can determine if that relationship will be beneficial based on the demand of your patient base. You have better odds of reimbursement as a participating provider. This will also put your practice at an advantage, allowing you to stay competitive across multiple avenues. You’ll find that if you’re growing your practice, physicians will be more likely to join a group with a larger network because of the benefits of credentialing.
The next step is to evaluate the contractual rates assigned at the time of your enrollment. Many physicians do not bother to negotiate their rates as it can be another intensive process or they were simply unaware that this was a possibility. Great news - this is in fact an option and a great way to boost revenue for your practice!
When assessing your practice's financial health, it should be quite apparent where your revenue is generated from. Your financial reporting should identify your top paying carriers as well as your top-billed procedure codes. In pursuing higher reimbursement rates, you’ll want to begin by reviewing what the customary rate is for your region. You’ll then need to demonstrate the value that your practice can bring to the insurance network. One of the biggest factors to highlight is the cost savings you’ll provide due to your clinical outcomes. Another beneficial attribute is location and specialty. Is there a shortage of your specialty in the area? Will you continue to grow your practice consistently to offer a larger network for their patient base?
Now that you have secured your contracts with payers and negotiated those contractual rates, your reimbursement will ultimately depend on the success of your eligibility verification process.
Unfortunately, many practices have experienced a scenario where the patient presented their insurance card, the billing department has submitted the charge to the carrier, and you later learn that the claim has been denied due to “subscriber not found” or “provider out-of-network.” Where do you go from here? Did your front office have the patient sign a waiver, such as an Advance Beneficiary Notice to allow you to legally bill the patient? Do you attempt to bill the patient and still run the chance of not getting reimbursed as the patient is unable to afford the balance? These are the challenges and tough decisions providers face when not validating the patient's insurance prior to the visit.
Luckily, these scenarios can be prevented by verifying the patient's coverage ahead of the appointment. Implement a streamlined process that will allow you to check eligibility electronically. If you decide not to use an electronic eligibility solution, the alternative will require your staff to spend countless hours calling various payers and will likely result in missed eligibility checks, inaccurate responses, or limitations to the data that can be provided. Not to mention, some serious overhead costs.
By integrating with an electronic solution, you can identify the specific health plan the patient is enrolled in and therefore determine provider participation status. You’ll also identify the patient’s out-of-pocket expenses, such as the remaining deductible prior to treatment. This enables you to leverage these responses to collect the patient's copay or deductible at the time of the appointment and in doing so, eliminate lag time in patient collections as well as prevent those dreadful denials.
Running eligibility prior to a visit is a critical piece to ensuring your practice will be reimbursed for the services you’ve rendered. You’ve dedicated your time and hard work conducting your visits, let’s not let coordination of benefits stand in the way of you getting paid. Getting the eligibility responses is one thing, interpreting those responses is another. It’s possible that the insurance coverage will return as active but the patient’s primary plan is covered through what is considered an “Advantage Plan” and you may not participate in that network.
In all three scenarios, enlisting experts to help guide you through the credentialing, fee schedule negotiation, and eligibility processes as well as help identify key factors and trends is essential to seeing your revenue maximized. Here at pMD, our expert team provides you with the services and experience you need so you don’t have to navigate all this on your own. We offer free consultations and would be happy to evaluate your financial analytics to help maximize revenue for your practice!