Optimal Billing Strategies

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By Erin Cammarata
Erin Cammarata

With insurance reimbursements declining and the cost of doing business increasing, the processes O&P businesses use to ensure successful billing and collections must be as clear and straightforward as can be. The following points can help guide your practice to success and optimal billing strategies.

  • Verify insurance

    I have written about the importance of insurance verifications in previous articles and how correct and efficient insurance verification could be your most effective collection tool. The verification process itself outlines what should be covered by the third-party payer and the patient's responsibility. If done correctly, the verification should allow you to collect the patient's financial obligation on the device delivery date.

  • Retrieve documentation

    O&P standards and requirements are extensive, but the requirements are clearly described in the local coverage determinations. We should know what is required to have a compliant claim and what must be included in the chart to get paid and to keep that money from being taken back in a recovery audit. What I have found to be the most successful billing practice that helps cash flow is to be sure that all necessary information is in the patient's chart prior to billing. In O&P, we usually have about two weeks between the initial patient evaluation and device delivery. In this two-week timeframe, the administrative team should be focused on collecting the physician's notes, the detailed written order, and any other documents that are required to ensure payment.

  • Scrub claims

    When you "scrub" a claim, you review it to ensure all the key components are included and detailed prior to submitting it for payment. The purpose is to identify and fix problems prior to submission, which can decrease denials, save 30-45 days in your collections process by eliminating or reducing resubmissions, optimize billing, and increase your cash flow. Create a manual that outlines each payer's claim requirements and have your billing department use it as a checklist for scrubs. The manual should include a rule sheet for each payer that lists modifier rules, coding rules, diagnosis rules, etc.

  • Be consistent and persistent

    At my office, regularly following up on open claims is a key to success. Our standard is that every outstanding claim will be called on every 15 calendar days. This keeps each claim in an active status with the payer. The purpose of the call is to get a claim status and ensure the claim is moving through the payer's system correctly. Before the end of the call, we ask the representative for a call reference number. We then document the call by noting the status update and reference number in the patient's medical record, and place the claim in the queue to call again in 15 days. This process will continue until that claim is paid in full.

    The second part of this is being persistent. It is important to challenge the payer when a claim is not paid in a timely manner. You should not accept a response that the claim is not on file or the claim is still being processed.

    We need to ask better questions: Why is the claim being held up for processing? How can this claim be escalated to priority processing? Refer to the previous calls and use the reference numbers to challenge the representative and move that claim forward. The claim status for the second call should not be the same as the first. Ask specific questions, for example, "This claim is already 30 days old; how can I get it processed more quickly? Can I fax it to you?" If a claim is over 60 days old and it is still in process, ask how to expedite the payment process, and if necessary, ask to speak with a supervisor. Press for specifics until you receive a commitment for payment.

  • Respond immediately to ADRs

    If a payer sends an additional documentation request (ADR), send the requested information back as quickly as possible. The goal is to collect the money you have earned in the fewest number of days possible.

We use these strategies with success, and they will optimize your claim submissions as well.

Erin Cammarata is president and owner of CBS Medical Billing and Consulting. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors. For more information, contact .