Years ago I read a news story titled “The Check Is Not In The Mail”. It was a fascinating story about a health care organization called Athenahealth that did a brief study on how the nation’s seven biggest health insurers pay their bills. What they found wasn’t shocking to anyone who’s ever had to try to collect on hospital or physician’s bills for a living.

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They had incidences of companies saying they didn’t have copies of their bills, even when the provider had a signed copy of a registered receipt. They had insurers telling them that they were limited to only so many questions per phone call. I’ve dealt with many of these issues over the years.

The story also talked about some of the excuses payers give in delaying the payment of claims, and how it ends up costing providers in time and expenses on the back end, with most of the costs being passed along to the patients. It mentioned that at least 40% of the denials can be tracked directly back to poor or incorrect information being sent by the providers; that’s a statistic that drastically has to change for health care providers, especially in today’s world where proper information can get claims paid faster.

What also wasn’t particularly surprising was how quickly representatives of all the insurance companies were to dismiss the findings as unscientific, while also claiming just how proficient they really are, based on the number of claims they have to process on a regular basis. I remember having local insurance companies state that all claims are processed timely, and that there’s no reason to ever have to call an insurance company because all will be handled in a timely manner; yeah, right!

The real world doesn’t work like that, as most of us know. We have valid reasons for picking up the phone and calling insurance companies to ask them where our payments are. When I see someone touting that they average time for paying claims is 30 days, I’m reminded of the fact that average means there are some claims that ultimately take much, much longer, and those are the ones that drive up our days in receivables. I also know that it varies from state to state, so whereas a state like New York says claims must be addressed (that’s an important distinction between being “paid”) within a certain period of time, that rule doesn’t cross state lines all that often.

Outside of providers who net their receivables at the time of billing (which is misleading and dangerous in my opinion), how many of you out there are actually averaging even close to 40 or 45 days in receivables? In all the years I was a patient accounting director, I hit 44 days during one absolutely great stretch that lasted about two months, totally gross receivables, before one of my billing people left to take another job. I wasn’t allowed to replace her for another 4 months after that; it never happened again.

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That was with our lag time of six days before dropping bills so medical records could get them coded. Even when things were going well, we had claims that were over 90 days in receivables that had nothing to do with self pay; we even had some claims still sitting out there over 360 days. Is there anyone who can’t identify with that?

Since it’s fairly obvious that the insurers aren’t going to willingly accept any blame for their shortcomings, and, as most management and motivational speakers will say over and over, that one can only change themselves, once again we need to take a look at what the providers can do for themselves to help get their claims paid quicker and easier. The following are some things you should look at, or have verified, to help out.

1. Know your insurance contracts.

Most of us try to learn everything we can about Medicare regulations, but after that things start to fall apart. Every one or two years, there’s a new contract with most insurance companies, and almost always something has changed. Since most of the time your contracts are negotiated by someone who really has no grasp of the billing process, you need to try to find out as much as possible as it regards these contracts.

Each month, the major insurers usually send out some type of bulletin describing changes they expect to see in new bills being submitted. Oftentimes, this information, if read at all, isn’t passed along to the people who are responsible for these claims; that needs to change. Much of the information, old or new, can usually be found on the insurers website, but too often employees are blocked from using the internet at work with worries that they’ll be doing other things instead of working.

On one of my consulting assignments, in discussions with a major state payer, I learned that there was a system error for this particular insurer that had gone on for upwards of two years that very few people in the state knew about, yet it was posted on their website. The error message on the explanation of benefits didn’t allude to where the information could be found, and the people responsible for this insurance company at the hospital I was consulting at never thought about picking up a phone to call and find out what the error message meant. If someone had been monitoring the online directives, or even been allowed to use the internet to access the website, they would have discovered this particular error sooner.

2. Request a review of your charge master, or do it yourself.


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It never ceases to amaze me how many charge masters have revenue codes ending in “9”, which designates “other”, or unknown services, instead of the correct revenue code, or even the generic revenue code category. This may be fine for your major insurers if it’s in the contract, but it gives other insurers a good reason to deny or delay payment on your claim.

There are many procedures that need something else to be billed along with it to be considered for payment. Things like not billing anesthesia when you have recovery room charges, not billing an expected C-code item with a procedure, or not billing a pharmaceutical along with an injection, will delay your claims.

Coding an item with an improper revenue code in order to get it paid, while knowing that it’s not exactly proper (as in coding something as a clinic because you’ve contracted clinic payments, but you know it’s not a clinic), is not only improper but fraudulent, and it could get someone fined or jailed. Pleading ignorance may work, but it usually doesn’t. Verifying that your groupings are correct, such as making sure your supplies aren’t coded as procedures and vice versa, is crucial. Making sure that all the services you bill have a price on them won’t hurt either (surprising how often I see that).

3. When reviewing unpaid claims, be thorough when verifying demographic and billing information.

I can’t count how many times my mother had to call the provider of services for my grandmother years ago because they’d put my mother’s name on as guarantor, since she handles all my grandmother’s bills and was always the one making the phone calls. The bills often got denied and had to be rebilled because of that error. Easy things such as the incorrect sex or date of birth are inexcusable, but happen on a regular basis. Verifying primary insurance for a child or someone of Medicare age is critical. Checking active dates of service can save you time and embarrassment.

4. Don’t be afraid to pick up the phone and call someone.

Patient or insurance company, your role is to get your medical claim paid. If you need correct information, or need to find out the reason a claim isn’t paid, sending a letter is the easy way but also takes a lot of time.

In the scenario I mentioned on point number one, the acting supervisor didn’t want to call the insurer, hoping there was another way around the issue, but also wouldn’t let the billing personnel call either. Without calling the insurer, we’d have never had the answers that were needed to correct the billing issue, and I wasn’t about to do what was requested of me without confirmation from the insurer (which I knew was illegal and had confirmed by making that phone call). It’s always better to get it right than to continue getting it wrong; it’s certainly more financially beneficial.

Someone has to step to the plate and be ready to accept responsibility for getting claims paid more timely. If the insurers aren’t going to cop to their part in the process, the least medical billing departments can do is minimize their own errors and lack of proper processes.
 

Last year we had an article here talking about reasons to consider assisted living. It was more about the needs for assisted living and the potential emotions associated with it by the residents.

Sophia Playing the Harp
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This time around we’re going to address issues around assisted living centers that most people don’t know, things that may help you decide if it’s the place you want to put your loved one into. After having to go through the process with my own mother I’m sharing some of what I’ve learned.

1. Assisted living organizations don’t take insurance

Assisted living isn’t a senior care center. The idea is for it to be a place for those of a certain age who can pretty much take care of themselves but might need some minor assistance. Many of them might be older, but that doesn’t necessarily mean they’re not pretty healthy.

Because of this, insurance isn’t going to cover any of the bills; at least not those generated by the assisted living center. They will help coordinate visiting nurse services if requested by a physician, which will be covered by those of Medicare age. Otherwise, it’s going to be totally out of pocket at this level.

2. How much money you have to spend monthly

Believe it or not, this is the 2nd most important thing to know, even moreso than what the monthly rates are. Many of these facilities are going to want to set up automatic withdrawal, which means you need to make sure the resident has the funds to last them for a long time. The income level is going to need to be somewhat significant; don’t even think about looking into assisted living if you can’t spend at least $4,000 a month. This isn’t all “fee” though; I’ll be addressing more below.

3. How much monthly rates are

This is actually the 3rd most important thing to know. Assisted living fees are different across the country and even across your own area. I live in the Syracuse NY area and fees run from between $2,300 and $4,800 a month.

As you can imagine, the least expensive fees are probably in large facilities in urban areas, and the most expensive fees will be in very nice settings with a bit more exclusivity. But wait; there’s more.

These facilities will have rooms of different sizes, from studios to 2-bedroom “suites”. Don’t think apartment sizes for these prices; they’re probably less than half the size of a traditional 2-bedroom apartment.

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One that I looked at had what they called a studio apartment which was 100 square feet; that’s the size of a small home office. It didn’t include cable or phone, but it did include heat, and since older people are always cold this might not be a bad feature. Meals and activities will be included in the fees, along with some limited travel and transportation to doctor’s appointments or to the store if you request a small refrigerator in the room.

The more you can spend, the nicer a place you can get, but you’re going to want the resident to have enough spending money to enjoy themselves.

4. How nice are the facilities

Once again this is based on location and price, but even pricey assisted living centers might not be all that nice. There was one assisted living facility that was very spacious and well laid out. It had multiple sitting rooms and game rooms, and even an exclusive room where there was a piano and extra large TV for movie night.

The big spaces can be really nice. Other spaces might seem a bit oppressive. Some residents might end up having to share a room, just like in a hospital, and that’s not always a pleasant experience. Also, some facilities aren’t as clean as you’d hope they would be, especially if they have a lot of residents. Unfortunately, most of the people working in these larger places don’t make a lot of money, so it’s hard keeping quality help.

5. What recreational opportunities do they have?

Sitting Room
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You like to know that your family member will be mentally and physically engaged instead of having to sit around watching TV. Most of these facilities will offer games, dances, sing alongs and movies, but the larger the places are, the less likely they’ll be in making sure everyone participates as often as you’d hope. Smaller facilities have employees that get to know the residents pretty well, and in those cases the residents will be encouraged to participate in these things more often. By the way, this one comes from talking to residents of different facilities and their experiences.

6. What are the meals like?

Some assisted living facilities have almost world class chefs and fancy meals and desserts. Some will have standard comfort food, while others might have sandwiches and one daily special for lunch or dinner. No one will starve, but the food might not be all that flavorful since dietary concerns become the norm.

Also… well, this one’s not quite fair, but it was an observation I had at one facility. There was a large dining room and I was there during lunch. Half the tables had residents who were still in their night clothes or robes, and sitting at tables either ignoring each other or just looking… old. A few tables had great engagement and laughter, but strangely enough those tables were all male. I’m not sure what that says overall but I have to admit that it gave me pause, thinking that my mother might be at a table where no one was talking or showing any life.

7. Are there hidden fees?

This one is the most important thing you have to find out about. Many facilities will offer different levels of care based on tier pricing, in which case you know what’s going on up front. One of the facilities I looked at gave us a price list of extras, and some of them seemed a bit outrageous. Since they determine which extras your family member might need to receive, it’s possible that your monthly bill could end up being as much as 300% higher than the actual monthly rate… being automatically withdrawn without your prior approval. That will eat up savings pretty quickly.

Truthfully, it was this last one that convinced my wife and I to move my mother into the house with us. It’s turned out to be the smartest move, and we can make sure that her money is safe and that she’s well taken care of.

Most people will have to think about assisted living at some point in their life. I hope this has been helpful.
 

Just like almost all businesses large enough to have employees pay someone to audit their businesses, hospitals sometimes need to, or should have, someone come in to audit their receivables process. It can involve looking at the charge master or how charges are captured, or a host of other things. This article is specifically going to talk about the billing process because it’s one of the most critical parts of the hospitals financial health.

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In general terms, we start talking about receivables when the billing process begins and it’s time to try to collect payment on the charges submitted by departments within the hospital. A review of receivables usually means looking at the billing process because it can be unwieldy and complicated… or has been made to be so over time. Depending on the depth a hospital is looking for, a review can take a week, or it can take a month or more.

Below is a portion of a paper I wrote for a magazine years ago on what it take in doing a billing review:

“If I were going to go in and do a billing review, I’d ask for some things up front. One would be an age trial balance, which would then allow me to look at both new and old accounts and give me an opportunity to look at why older accounts weren’t being paid. I’d then want to review one of these accounts on their system, or in their billing records, and of course review any notes they had on these outstanding claims. You can learn a lot by reviewing as few as 25 to 50 claims; that’s how insurance companies do it when they come in to review claims specifically for them.

I’d ask for a copy of billing and collection procedures, if they had any. I’m someone who believes that no department can be run properly without having a lot of their processes down on paper.

I’d ask for EOBs (explanation of benefits, also known as vouchers) for a one or two month period. This would allow me to scope out accounts that look problematic so I could determine whether it’s procedural or something out of the control of the facility… which eventually means it’s procedural. I’d be checking to see how long it took to post payments and allowances, if they posted the correct allowances (also known as adjustments), and how long it took to bill either secondary insurance or the patient.

I’d also be looking at denials, and I’d probably take one full month for their top 3 or 4 insurance companies and see what the denials were, and what their frequency was. Denials aren’t always billing’s fault, but sometimes they are if they’re not being worked properly. Sometimes this leads to looking at the medical records for some of these patients because sometimes I’ve seen billers taking it upon themselves to change codes just to get bills paid; that’s a major definition of fraud.

I’d also want to interview some of the billing personnel. If it’s a small group, I’d want to talk to everyone independently, and if it’s large, then I’d like to talk to a random number of them, without the supervisor or manager around. That would give me a chance to ask them specific questions on how they do their work, and each person would be asked the same questions, to find out if everyone handles claims the same way, or if each person does their own thing.”

That’s the basic process in doing a full review of a hospital’s billing department. The one thing I like to make clear is that this isn’t a witch hunt. The idea isn’t to determine if management is deficient or to get anyone into trouble. After all, those people need to be there to handle things when the reviewer leaves. Any report will detail the findings and hopefully make recommendations that can be implemented to get things working properly. I say that because years ago when I was a director and we had a review, every recommendation was “put more people on…”; that wasn’t helpful one bit.

There you go; that’s the entire process. How does your facility handle things like this? If you have any comments or questions, please post them below.
 

Every person who works with hospital bills know something about revenue codes. Some folks have at least a basic concept of what revenue codes are supposed to be, that’s about as far as it goes. Scarier yet, some people have only heard the term. It would seem that it’s time someone addressed revenue codes in […]

I made one of those critical mistakes those of us can make who are trying to take care of our elderly parents and don’t have any of the skills needed to do it right. I recently discovered that one of the major reasons my mother was having trouble walking is because she hadn’t been taking […]