Last week, we discussed how you can spot weakness in your revenue cycle management. This week, we’re going to evaluate our reimbursement systems and see how they can be hurting the financial performance of your practice.
Reimbursement Systems
As you saw last week, three of the five areas listed in the previous blog focus on revenue cycle management. Under the area of reimbursement systems, appropriate coding has been determined to be the single most important element for practice improvement, given that the majority of all providers under code. Therefore, implementing a coding compliance program usually leads to revenue enhancement. For providers who tend to over code, the implementation of coding appropriateness reviews may lead to decreased audits and a reduced chance of facing civil or criminal penalties.
Many organizations depend on their EMR software system to code for them, having been told by their sales consultant that they will not need the expertise of a coder because the ‘system can do this for you’. Physicians/Owners should beware when they are told this as there is no software system on the market that is able to read the provider’s mind and appropriately code a chart. Prior to reducing your workforce, an Urgent Care provider should ensure that they have compared their EMR product with AMA guidelines to ensure that it properly credits a provider for the services that they are performing. Inappropriate E/M level coding not only could lead to a loss of revenue but worse yet it could lead to monetary penalties under the False Claims Act.
Another issue related to reimbursement involves the organization’s fee schedules, which typically are inadequate to meet the rising costs associated with providing services in an Urgent Care facility. Many organizations take an associates Family Practice fee schedule in the area and utilize this as their rates. This is often inadequate under managed care contracts. Since most start-up Urgent Care centers do not know the true cost of delivering patient care, they try to cover their expenses under fee schedules that are not proportionate to ensure that costs are covered. Another problem is when organizations contracts, with all their plans in terms of global fees, are once again underpricing their services, as well as not covering the basic cost to perform those services.
While improving reimbursement systems usually results in a quick and positive effect on profitability, the areas of coding, fee schedule analysis, and managed care contracting requires continuous monitoring and management if physicians/owners want to see a steady increase in practice revenue.
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Medical Practice Success, LLC is a premier full-service Revenue Cycle optimization organization that assists Hospitals, Multi-Specialty, Surgical Centers, Specialty, and Urgent Care organizations with services that include coding and documentation training, medical practice analytics, managed care contracting analysis, credentialing, billing, practice enhancement initiatives, and so much more.
