How To Optimize Practice Revenue While Improving Patient Care

By David Wyatt, Greenway Health

The evolution to value-based care is delivering enormous benefits to patients, ensuring they receive better care at lower costs while also driving practice efficiency. While this certainly improves the patient’s experience, providers must make sure they have the right strategies and tactics in place to also improve their practices’ revenue stream.

The goals of enhancing the patient experience and strengthening a practice’s bottom line do not have to be entirely opposed. Services that provide great value to patients — such as office visits and chronic care management — also tend to be the highest paying offerings for payer reimbursements. By ensuring patients receive ongoing care to promote a healthy lifestyle, while increasing office efficiency and correctly billing for these services, providers can improve their practices’ profitability at the same time.

Steps For Increasing Value-Based Reimbursements

The first step is to determine what the highest paying services are that also deliver the greatest value to patients. These services can vary based on many factors — from the payers to the practice specialty to the patient population being served.

Office visits, for example, tend to be the highest paying services for primary care or family practices. Practices with a large Medicare population should focus on annual wellness visits for preventive care, in which providers may choose to do additional screenings — such as for depression and anxiety, or bloodwork — to establish baselines at the first visit and to monitor changes in health in subsequent years. Internal medicine practices may offer additional high-value services, such as colonoscopies or minor surgical procedures.

Pediatric practices function much like primary care and also offer immunization visits. There are, however, complexities to billing for these services, distinguishing from post-partum care to individual child care as a child transitions from the mother’s insurance. For obstetrics-gynecology practices, global OB packages, antepartum care, and ultrasounds tend to be the highest paying, as well as most frequently offered services.

Practices committed to increasing value-based reimbursements should also consider chronic care management services, which can add a new stream of revenue. Chronic care management involves patients who have two or more conditions that are expected to last at least 12 months o, in which a comprehensive care plan can be implemented and monitored. These services can be provided by a physician or non-physician practitioner — including physician assistants, nurse practitioners, clinical nurse specialists and certified nurse-midwifes — and their clinical staff.

The Importance Of The Billing Process

For any of these examples, reimbursement depends on contracted rates, which will vary by payer. Properly billing each payer efficiently and accurately can pose quite a challenge, because 96 percent of practices report inefficient billing processes. Many practices are not sure how to resolve the problems due to a lack of solutions or technology that assist in the process or the time and resources needed to figure it out. This problem is compounded when you consider that an average practice typically deals with 10 or more payers, each with their own fee schedule and billing requirements.

To address these challenges, practices should ensure they understand all claims requirements for each payer, including if the patient is covered for services, the codes for in-office or outpatient care, what documentation and patient demographic information is required, the necessary modifiers, and when to bill for services.

Even with a comprehensive understanding of these requirements, denials are inevitable and can impact a practice's revenue stream, which can lead to frustrated patients. To avoid denials, practices should pay close attention to:

• Eligibility and benefits – Get a copy of patients' insurance cards, check for data entry errors, verify eligibility and benefit coverage, and obtain authorization when needed.
• Procedure codes – Use a valid procedure code and modifier for services provided and the patient's age, and make sure you have a valid NCD code or description.
• Changes to diagnosis codes – Stay on top of new, changed or deleted diagnosis codes, which are released and become effective on Oct. 1 each year.

In addition to avoiding denials, practices should ensure they're maximizing reimbursement rates by focusing first on the highest valued services and being paid accordingly. Routinely reviewing payments can ensure practices are receiving their contracted rates, as well as identifying and recouping underpayments. Practices should also update fee schedules annually and renegotiate contracts with payers as the expiration period nears.

By not having strong billing processes in place, practices stand to lose a lot. Take, for example, a seven-provider OB-GYN practice that was faced with an entire year of denied claims because the date of service field was not consistent across all their payers. By training staff to bill accurately and improve data entry, the practice reduced its time to post charges by 50 percent, increased average monthly receipts by 25 percent, and saw a 6 percent year-over-year increase in rate per encounters. The practice also was able to increase its clean claim rate and decrease days in accounts receivable by 15 percent.

Practices do not have to sacrifice their business goals in the move to value-based care. By delivering necessary, yet high-value, reimbursable services, providers can strengthen their relationships and improve the health of their patients while also increasing revenue. Keeping a close eye on billing requirements, improving processes, employing revenue management solutions, taking steps to avoid denials, and ensuring proper payments all play a vital role in maintaining and growing practice revenue during this transition period.

About The Author

David Wyatt is the vice president of revenue and clearinghouse at Greenway Health. Wyatt has more than 25 years of experience leading large operations and services organizations. Over the past 12 years, his focus has been in healthcare technology and services. His primary focus at Greenway is to fuel customers’ success through innovation and growth through Greenway service offerings.