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Revenue Cycle Management of a pediatric practice is a team effort. Influences on pediatric revenue cycle performance include the front desk team members, medical assistants, providers, and the medical billing team. Previous blog articles include articles on the importance of each of these roles, and the potential impact they pose on practice revenue. The medical billing team has a number of roles and duties that occur on a daily basis. This includes, but is not limited to, the reviewing of claims, making adjustments (i.e. modifiers), managing claim edits, managing payer rejections, handling appropriate claim resubmissions, sending out patient statements, conducting patient statement follow-up, and management of inappropriate claim denials. The account managers at PhysicianXpress manage these functions for pediatric practices on a consistent and continuous basis.
Payers can enhance their profit margins by increasing claim denials and inserting additional barriers. The systems and processes of the PhysicianXpress billing team facilitate identification of these payer denial issues, management of necessary claim adjustments, and the resubmission of said claims. An example of an inappropriate payer edit would be a managed Medicaid payer that denies payment for well-visits that have been appropriately coded for a specific age group, regardless that the claims were initially coded correctly and the payer has been reimbursing for years.
The PhysicianXpress billing team manages and documents follow-up on denied claims, with a routine approach until the claim is appropriately reimbursed. A few Blue Cross Blue Shield plans had some issues with appropriately managing an out-of-state BCBS carrier. Additionally, a few payers were not prepared for appropriate reimbursement on the COVID-19 administration CPT code associated with the 3rd COVID-19 vaccine. The account management team is adept in identifying such issues, and will then work with the payer to ensure that a practice receives appropriate reimbursement. While some of these denials can be managed electronically, others may require the submission of a paper claim.
Understanding and overseeing the denial management process is a critical component of the work done by the billing team at PhysicianXpress. This work is what leads to optimal practice revenue. Many of these payer denials require follow-up calls to insurance representatives that specifically handle claims management and/or provider representatives [when dealing with a more widespread issue].
While the PhysicianXpress account management team has a consistent process that we implement for each practice, there is still variability among the total collection rate by practice due to inconsistencies among respective practices’ front desk team members. Practices that obtain the highest collection rate to that of the contracted amount tend to have the most consistent front desk team in verifying insurance and confirming patient demographics at each visit, in addition to collecting co-pays and current balances. The PhysicianXpress account management team has consistent follow-up with payers and patients to encourage an average of 99% collection rate of the contract amount. While few practices achieve slightly less than 99%, some practices achieve over a 99.6% collection rate of the contract amount. The difference is attributed to front desk team performance and consistency.
