Getting the Most from Your Practice by Looking Within: Part 1 of A Four-Part Series

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By Christine M. Duprey

Accounts Receivable Workflow: Is It Working for You?

Analyzing your O&P business can be intimidating. The necessary time, resources, and money to examine your business from the inside out are not always available. To help you in this endeavor, The O&P EDGE is offering a series of four articles that will focus on key elements of your business and provide some tips for performing analyses and improving your processes.

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The first article in this series focuses on improving your processes to minimize outstanding accounts receivable (ARs). Outstanding ARs are a result of workflows that are not working well-claims that are not being paid on time or are being denied-and managing that process efficiently starts before the first office visit. The processes outlined in this article will help set you on the right path for effective AR management and a healthier bottom line.

1. Gather patient information: Prior to the patient arriving at your patient care facility, collect information necessary for documentation and billing. This includes evidence of insurance coverage; a copy of the patient's driver's license or other form of identification for verification, if possible; the patient's current address and contact phone numbers; a prescription from the referring physician; and when appropriate, the certificate of medical necessity. To avoid delays or denials, order the patient's medical records prior to his or her visit to ensure you have all of the information you need to bill and substantiate medical necessity.

2. Perform patient intake: At the patient visit, be sure you have collected all of the data necessary so appropriate verification of benefit procedures can be started. If you have not received them prior to the appointment, scan or copy the patient's form of identification and the front and back of all insurance cards. Make sure the scan or copy is legible and "faxable" in the event you have to fax the information to the physician's office or insurance company.

3. Document the patient appointment: Establish a standard charting procedure within the office to ensure all practitioners are documenting uniform and appropriate information from each patient visit to support the claim that will be submitted. Documentation must include specific information regarding the patients' capabilities and limitations, and recommended services. Recommendations regarding devices must be consistent with physician documentation in the patient's medical record.

4. Verify benefits: Once the services to be provided have been determined and the treatment plan has been documented, call the insurance company or companies to verify the patient's available benefits for the recommended services. It is critical for the office staff to be able to articulate these services and that they do not just ask for verification of durable medical equipment (DME) benefits, which is the category that O&P is listed under in some policies. Although prosthetic, orthotic, and pedorthic devices may fall under the DME category, there may be specific inclusion or exclusion of policy benefits for certain services, such as custom shoes and orthotics. Supply the insurance carrier's verification of benefits representative with the exact Healthcare Common Procedure Coding System (HCPCS) codes to eliminate misunderstandings, and document the representative's name and the information she or he provides. Verify the patient's deductible and how much of that deductible has been met year to date. If the patient has more than one insurance carrier, verify primary and secondary positions for billing. An unplanned denial of coverage could result in a substantial out-of-pocket expense for the patient. If prior authorization is required, be sure it is received before the patient's device has been dispensed. Occasionally a backdated authorization can be obtained, but in those cases where it cannot, the provider typically cannot bill the patient and thus becomes responsible for absorbing the cost. (Not obtaining prior authorization is one of the top write-offs providers make, and it can nearly always be avoided.)

5. Estimate and communicate patient liability: Based on the information gathered from the insurance company, such as the allowable benefits, the patient's deductible, and how much of the deductible has been met to date, estimate the patient's financial responsibility. Present the estimation of benefits to the patient in a formalized manner that clearly articulates the services to be provided and diagnosis indicated by the referring or ordering physician that was used in the verification of benefits process. This will ensure proper documentation of the verification with the carrier and that the communication of expected patient financial responsibility is clear and understood by all parties. Let the patient know that you have verified his or her insurance benefits as a courtesy, but he or she should verify coverage as well. Also tell the patient that the insurance company does not guarantee benefits, and you are providing an estimate based on the information that you were able to verify. It is also important to indicate to the patient that when initially questioned about coverage for these services, insurance companies often provide information about DME benefits. However, the patient should ask the representative to look specifically for the prosthetic and orthotic coverage within a policy. In some cases, the benefits or the exclusion of P&O devices is located in the Limitations and Exclusions part of the policy benefit document. By communicating the financial impacts up front, the patient is aware of, and can plan for, these out-of-pocket costs. Have the patient sign a financial agreement that indicates in the event the insurance company does not pay, regardless of the reason, he or she is responsible for the full cost of the services or device provided. Make sure the patient reads and understands this agreement.

For an item covered by Medicare but not for the condition or purpose the patient is receiving it, you are required to have the patient sign an Advance Beneficiary Notice (ABN) in order to charge the patient for the cost of the item. However, if the item is covered by Medicare for the patient's condition, an ABN is not necessary. Be sure to follow the ABN guidelines for situations in which you must have this document completed and on file for proper financial responsibility.

6. Order the device or begin the custom-fabrication process: Managing inventory and efficient ordering is important for overall cost management. Keep clear and current inventory records to help you avoid ordering something you may already have on hand. Know what stock turns the most, and manage the ordering and availability of these items to ensure you are able to meet patient needs. For items that require customization, be sure to provide the fabrication lab, whether an in-house or independent facility, with orders that are clear and well-documented, and include the date the device is needed. Clear communication with the fabrication lab helps to ensure the device delivery date is met. If you are unable to determine the dispense date immediately, inform the patient that you will call him or her with that information as soon as you receive it and again to schedule the dispense appointment. Keep the patient apprised of any delays.

7. Dispense or fit the device: The appointment at which you dispense the orthotic or prosthetic device is the last chance to ensure all documentation has been completed and all required documents are in order, including the prescription, medical necessity documentation, referral source documentation for face-to face visits, ABN if it was necessary, financial agreements and authorizations, and insurance information. Depending on the timeframe between the initial visit and the scheduled dispense appointment, you may need to reverify benefits and confirm the patient's out-of-pocket costs prior to the appointment. If there has been a significant change to the benefits, the out-of-pocket costs, or the patient's coverage, notify the patient before the appointment. This provides a chance for the patient to contact the insurance company for coverage issues that may exist. Collect all co-pays, co-insurance, and all amounts for noncovered items at this appointment; this will reduce your patient-related outstanding ARs, which are difficult to collect once the device has been dispensed.

8. File the claim: Carriers have different claims payment platforms, and the claim information is processed differently depending on the setup of these systems. For example, a carrier may require that a claim for a pair of therapeutic shoes lists each shoe on a different line with appropriate left and right modifiers, while another carrier may be able to process the claim with the pair of shoes listed on one line along with the appropriate left and right modifiers. By understanding what is required with the submission of each claim, such as whether a particular, commonly dispensed device will always require documentation for medical necessity determination, or whether the referring or ordering physician face-to-face note is required to process the claim, you can eliminate unnecessary payment delays. If a particular payer requests additional information 80 percent of the time, try to anticipate what additional information is typically requested and send it as support with the original claim; this should reduce the claim processing time. Keep in mind that when a payer requests additional information, the claim processing procedure must start over. Bill all necessary information, and submit clean claims to third-party payers. Claims should include the referring physician's or ordering physician's name, HCPCS codes and appropriate modifiers, prior authorizations, and current patient information. Be sure you are billing the primary insurance carrier first since billing the secondary carrier first will delay your revenue by an additional 45 days or so.

9. Follow up with the payer: If you are submitting claims electronically, clean claims should be paid within 30 days or sooner. If you are required to submit additional information to support the claim, expect the claim processing time to be 45 days at a minimum; these claims are not processed automatically but require review by a representative. Note on a calendar the anticipated date by which the claim should be paid, and if payment is not received, call the insurance carrier to determine where in the process it is. This will help you keep tabs on your outstanding ARs. Medicare claims are typically processed electronically in seven to ten days, and follow up can be done at the 30-day mark. Establishing efficient workflows that take into consideration the entire process of gathering the correct information up front and following the claim through to payment will decrease the amount of time your claims remain outstanding and minimize unpaid patient balances for your clinic.

Christine M. Duprey is the owner of Caris Consulting, Abrams, Wisconsin. She can be reached at 920.826.5300 or at