Inside Secrets For Maximizing Reimbursement

By David Edward Marcinko, MBA, CMP, and Hope Rachel Hetico, RN, MHA, CMP

When one speaks of maximizing medical practice reimbursement, most physicians immediately think of the National Correct Coding Initiative (NCCI) or coding-oriented consultants. However, bolstering reimbursement involves more than just using the newest Current Procedural Terminology® (CPT) codes, parsing old codes or even becoming a CPT coding expert.

It is the entire economic compliance ecosystem that surrounds the office cash flow and revenue recognition cycle. This cycle is defined as the process that serves patients, accounts for receivables and collects those receivables from a third-party payer.

In this context, our preferred term at the Institute of Medical Business Advisors, Inc., is Revenue Cycle Economic Compliance™. When this is codified and implemented as a transferable business process, it is more economically sound in the aggregate than any isolated reimbursement event.

Furthermore, we have found that in an era of declining reimbursements and the increasing threat of Medicare and other carrier audits, one potential solution to the financial conundrum may be an internal control system program that helps identify and correct issues before outside agencies get involved. Fortunately, a Revenue Cycle Economic Compliance Program (RCECP) does not have to be complex. It can actually be functional and proactive for one’s practice.

Can A Revenue Cycle Economic Compliance Program Benefit Your Practice?
We have been using our proprietary form of the Revenue Cycle Economic Compliance Program for the last several years. Its purpose is to decrease workflow and maximize medical practice profit (not necessarily revenue) by about 10 to 15 percent.

While results from implementing this process are not predictable, our clients often are delighted to learn this internal office process also streamlines and integrates many insurance and governmental regulations with reimbursement guidelines. While it may or may not involve all the Centers for Medicare and Medicaid Services (CMS) and other managed care services contracting, accreditation, LEP standards or federal requirements of HIPAA, CLIA, EPA, DOT, ERISA or OSHA, etc., it is a reasoned and transferable system and not just a CPT coding “tips and pearls” initiative.

Indeed, having a RCECP can be beneficial as doctors currently are working harder, making much less money and are facing more potential legal sanctions than ever before.

In the not so distant past, doctors were seen as infallible and beyond reproach. With the current complexity of the healthcare delivery system, as well as fiscal mandates with the Deficit Reduction Act (DRA 2005), the business and administrative functions of medicine have increased confusion and highlighted questionable behaviors.

For example, most medical practices report revenues upon tendering the service. Yet many medical practices adopt the cash (not accrual) basis for revenue recognition. This creates an increased recordkeeping burden for tax preparation purposes as cash accounting is generally converted to the accrual basis for loans, lease applications or other purposes.

Of course, the most dramatic examples have appeared on the revenue recognition and reimbursement side of medicine as both patients and payers have called for more accountability. For providers, the days of seeing a patient and getting paid at the time of service are gone because payment is often dependent on another party. Depending on reimbursement arrangements — discounted fee for service, Medicare, capitated reimbursement and/or other fixed or risk-sharing contracting arrangements, etc. — the emphasis is now shifting focus to both the overutilization and underutilization of medical care.

Seeing Beyond The Bottom-Line Benefits
Although the decision to develop and implement a RCECP is an important financial call, there are additional benefits beyond positive bottom line contributions. These benefits may include:

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