Welcome back to Revenue Cycle Decoded where we are making sense and decrypting revenue cycle for medical practice managers.
Today I want to talk about your front end revenue cycle processes and what can go wrong in the front end that can cause you to have rejections and denials on the backend that lead to more re-work, decreased revenue, revenue leakage, decreased cash flow, increased days in A/R, increased staff dissatisfaction, lower morale, patient satisfaction impacted - so many bad things happen, just from some simple front end revenue cycle things that can go wrong. So, we're going to talk about that today. Let's get started.
The first thing that can go wrong, and this is so, so common, are simple errors in data entry--maybe less of an issue today than in years past because now we have so many options in our practice management systems that are sending data back and forth to the payors, so we can confirm pretty quickly, in most cases, if we have an error, and it can be tracked down. However, it still happens, and it's so easy because we're humans, and we're humans entering data into systems. Some of those errors can be simple transposition errors in a name or how a name is spelled, or a date of birth, or a payor ID, subscriber number, member number, leaving off a "Jr." or "Sr." or leaving out a middle initial. All of these things can cause that claim to come back as a rejected claim and then that claim has to be re-worked and resubmitted, and that's going to cost you days in A/R. It's going to cost you time to look up the issue and re-send it. So, this is one of the most common things to watch out for. It's very important that whoever is entering that information in your registration systems is entering it accurately.
The second thing that can go wrong is benefits eligibility and verification. Many times, we're not checking that every time our patient comes through the door, and who knows what's happened in the meantime since that last visit. We may assume because our patient had Medicare at the beginning of the year, that now when she comes back to us in November or December, she still has Medicare. That may not be the case. She may have transitioned to a Medicare Advantage policy. Or she may be covered under a commercial policy and now Medicare is secondary. So, it's very important to confirm that the patient's insurance has not changed, and their demographics information has not changed, for example, their address. You want to make sure that is up to date. Maybe their commercial plan - they lost their job, or they switched jobs and now they're covered under a different commercial plan, or they're covered under a COBRA plan. It's very, very important to make sure that your front office people are checking your patient's insurance and subscriber, demographic information every single time the patient comes through the door. And just asking "has anything changed?" That's not good enough, because sometimes your patient has had a change in their plan, but they don't really understand because they got a new card that means they are on a different insurance plan, or something has changed about their plan. Maybe it's transitioned from a PPO to an HMO. So, make sure you get their most current insurance card every time they come through the door so that you can have the most up to date information on file and it is accurate.
Sometimes, things happen where the patient has lost their insurance, they're no longer covered by their insurance, and you may get the payment when you send the claim through, and then it ends up getting taken back when the company realizes that the patient wasn't covered for those dates of service. That happens, too, so again, very important to check and make sure your patient's coverage is accurate and verified and that they are eligible for the days of service that you are going to see them.
The next thing that can go wrong is prior authorizations. or more accurately, missing prior authorizations. More and more payors are requiring prior authorizations on more and more services. Some of them say they're simplifying, but we have seen on surveys that prior authorization is and continues to be a growing issue and, of course, it can be very difficult and time consuming, in some cases, to get those prior authorizations. Make sure that whoever is obtaining the authorizations for you, whether it's your front office staff or you have a prior authorization specialist, that they have access to payor gateways or portals or systems to request those auths if at all possible. If your staff is having to sit on the phone for 45 minutes to an hour trying to get authorizations, that really eats up their time, and it's not very productive. So, if you have systems and the payor has systems, use those systems. But make sure that they're getting them. And make sure they are aware of the services and procedures that require a prior authorization, that they are kept up to date. If you have a notebook or a binder or something that you keep with your staff that's doing your front office or doing your authorizations, make sure that's up to date with the services and procedures that are performed in your office that require those authorizations from the different payors. Otherwise, you could be missing out because your staff isn't aware that a service or a procedure now requires an authorization. So, keep up to date on that. Make sure they are obtained, and that information is put into your practice management software correctly so that it is included on the claim.
The last thing I want to mention is coordination of benefits. Very important that your staff understands how coordination of benefits works if your patient presents with more than one payor. For example, a patient has two commercial payors, and they need to understand the birthday rule. And we'll talk more about the birthday rule and coordination of benefits in a separate video. The other thing that they need to know is Medicare secondary payor. When is Medicare secondary? Some people think Medicare is always primary, but that's not the case. And so, they need to understand when Medicare is a secondary payor instead of the primary payor. And many systems now have a questionnaire that you can go through to answer that will then tell you which insurance is primary, and which is secondary if your patient has Medicare and another insurance plan. But that should be completed, again, every time your patient comes to see you because that information can change, so that needs to be updated at every visit. Make sure we're getting the correct order of the payors on the claim. Otherwise, you take the risk of the claim being sent to the wrong payor, the secondary payor first, and being denied, coming back to you, then you have to re-work that claim, send it to the correct payor and get paid, and then back to the secondary, and so, of course, it increases your days in A/R, slows down that cash flow and you may be missing payments that you could be receiving.
So, all of these things are things that can go wrong in those front office processes. That is one of the key positions in the revenue cycle. It's where everything starts, and we want to make sure we get those processes right so that we're submitting clean claims so we're getting paid properly for the services that we provide.
So, I hope this has been helpful to you. If it has, please like, and subscribe and click the bell down below to be notified when I post new content. Also, please visit my website, RevenueCycleDecoded.com. I do have a regular webinar where I go into revenue cycle for the medical practice manager. It is introductory, talking about the different pieces of the revenue cycle and how they impact the financial health of your practice with some very actionable steps for you. So, it's a free webinar, it's about an hour long. I invite you to go my website, check out the webinar information and sign up for a time that fits for you. Also, I want to remind you that I do have the Front-End Denials Decoded course available and, in this course, I go deep into front office, front end revenue cycle issues that can cause claims rejections and denials and how to solve and manage those rejections and denials so that you get paid for them. but more importantly, how to prevent them using systems and a team and quality improvement approach. And I think you will find it very helpful. It will definitely help you recover more money and help you improve your profit margins in your practice, decrease your days in A/R, and of course, improve your staff morale and your patient satisfaction because less time is being spent on re-work and patients are being billed correctly or their payors are being billed correctly. So, I think you'll find that very helpful. I hope you'll check them out. You can also listen to my podcast. I am on Spotify, Google and Apple podcasts and you can also find me on LinkedIn and on Facebook at Revenue Cycle Decoded, and on LinkedIn: Revenue Cycle for Medical Practice Managers. So, I hope you will find me, take a look at the website, RevenueCycleDecoded.com and finally, have a fantastic day. Thanks for joining me today.