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The Giant eBook for Billing and Operations
Medical Billing

The Giant eBook for Billing and Operations

eBook Overview

  • Chapter 1: Billing for Non-credentialed and Non-contracted Providers
  • Chapter 2: 7 Common Missteps in Urgent Care Coding and Billing
  • Chapter 3: Best Practices for Using a Practice management Software
  • Chapter 4: 10 KPIs to Watch in Your Urgent Care

 

Intro

In this industry, getting patients in and out fast is your biggest priority. But to be successful, it’s just as important to manage your billing accurately and efficiently. In this eBook find tips for billing non-credentialed and non-contracted providers, common missteps, best PM practices, and 10 important KPIs you should be watching. Be sure everyone involved in your billing and coding is committed to accuracy with the help of this eBook.

 

Chapter 1

Billing for Non-credentialed and Non-contracted Providers

A frequently asked question in the urgent care industry is whether or not   a practice can bill and receive payment as an in-network provider for a clinician (physician or mid-level) who is new to the practice but not credentialed or contracted with the clinic’s health plans.

This question occurs most commonly for the following situations:

  • Employed Full-time or Part-time Hire: As a practice grows rapidly, new providers are needed This is especially true in urgent care. Sometimes this need is unexpected, and a clinic owner may not have the four to six months advance notice needed to fully credential a new clinician.
  • Temporary or Substitute Hire: Another reason is unexpected loss of a provider (e.g. termination or leave without notice). A clinic may also have a clinician who is absent due to illness, pregnancy, vacation, or other situations where that  person  will be returning to work, and they need a short-term substitute

For these situations, practices often ask their billing company if they can bill for the new provider under the clinic name or under another doctor’s name. The answer is: it depends on the situation. Commercial insurance carriers will each have their own individual requirements, and Medicare also has its own policy regarding non-credentialed providers.

 

Billing for Employed Non-credentialed and Non-contracted Providers

Pay close attention to your payer contracts to know if you can bill for non- credentialed providers. If the health plan requires providers to be credentialed before providing services or if your new provider is not replacing anyone, you cannot bill for services rendered by that provider. A practice would potentially be in violation of their health plan contract if they billed for services not  provided by a credentialed provider. Some health plans require only physicians to be credentialed and tied to the contract, and some plans require all providers including mid-levels (CNPs, PAs, and other APs) to be credentialed.

On the other hand, if the health plan does not require individual credentialing, you can bill under the clinic name for new providers. In these cases, most health plans just need an updated roster of providers offering services under the clinic agreement. Medicare  requires that all employed (permanent full-time or part-time) providers be credentialed with Medicare in order to bill for the services provided.

 

Billing for Temporary or Substitute Non-credentialed Providers

The answer is more complicated in this type of situation.

Let’s look at the two billing options available for non-credentialed providers in this circumstance—locum tenens and reciprocal billing arrangements.

 

Locum Tenens Definition:

A locum tenens is a substitute physician, who fills in for a regular physician (the provider that is normally scheduled to see the patient) who is absent, but does not plan to permanently join the practice. Locum tenens usually have no practice of their own and move from area to area as needed.

 

Medicare Rule for Locum Tenens

Medicare allows aregular physician tobill and receive payment (when assignment is accepted) for a substitute physician’s services as long as the following criteria are met:

  • The regular physician is absent and unavailable to provide the services
  • The Medicare beneficiary has an appointment or seeks an appointment with the regular physician
  • The regular physican pays the locum tenens for their services on a per diem or similar fee-for-time basis
  • The locum tenens does not provide services for more than 60 consecutive days (even if a provider does not have a full-time schedule)
  • The regular physician identifies the services as locum tenens services meeting the above criteria by applying the Q6 modifier on each procedure (CPT) code billed

Medicare’s policy does not allow advanced practice providers (mid-levels) to be locum tenens. If a provider or group practice requires a substitute physician for longer than 60 consecutive days, it is a good idea to enroll that locum tenens provider with payers.

After the 60 day limit expires, a practice may no longer bill for that locum tenens physician.

After this point, it is important to know what your local Medicare Contractor (MAC) says about use of locum tenens. The practice must also keep a record of services performed by the locum tenens along with the NPI number.

Newly employed physicians that are not enrolled with Medicare cannot be considered locum tenens physicians.

 

Commercial Insurance Carriers

Verify with your payers what the terms of your contract are or what their billing policies are regarding the use of locum tenens physicians. Some health plans require locum tenens to still be listed as the rendering/billing provider and others may follow Medicare’s policy.

If you do not know the specifics of a health plan contract, a good rule of thumb is to follow the Medicare policy for locum tenens physicians until you have clear guidance.

 

Reciprocal Billing Arrangements

Reciprocal Billing Definition:

A reciprocal billing arrangement is an agreement between physicians to cover each other’s practice when the regular physician is absent. This is usually an informal arrangement, and is not required to be in writing.

 

Medicare

Services may be submitted under a reciprocal arrangement if all of the following criteria are met:

  • The regular physician is unavailable to provide the services
  • The patient has arranged or seeks to receive care from the regular physician
  • The substitute physician does not provide services to the beneficiary over a continuous period of more than 60 days
  • The regular physician submits the claim with a Q5 modifier with each service (CPT) code

Reciprocal  billing  is  another option  for urgent cares if locum tenens arrangements are unavailable  or  are no longer an option. Similar to locum tenens, reciprocal billing arrangements cannot extend past 60 days.

These stop-gap measures are meant to be a temporary solution, and Medicare assumes your clinic is working toward employing regular credentialed and contracted physicians to provide services.

 

Commercial Insurance Carriers

Verify with your contracted health plans to make sure you are following your contract and billing policies for reciprocal billing. If you do not know what is required by a specific payer, again, it is a good rule of thumb to follow Medicare policy.

 

A Quick Overview

Medicare:

Locum Tenens Billing

  • Not allowed for newly employed physicians
  • A locum physician with an NPI number may fill-in for 60 consecutive days. This means that even if the absent physician had a part time schedule (M-W-F),the 60 days count all days during that period, not just the worked days.
  • Mid-levels cannot be used as locums
  • Use modifier Q6 on claims

Reciprocal Billing

  • Generally the same rules apply as for locum physicians
  • Use modifier Q5 on claims

 

Commercial Insurance:

Locum Tenens Billing

  • Varies by plan and by region; know your contract!
  • May follow own rules:
    • May require all providers (physicians, NPs, and PAs, to be fully credentialed before billing)
    • May only require physicians and mid-levels to bill under practice or supervising physician
  • May follow Medicare rules

Reciprocal Billing

  • Varies by plan and by region; know your contract!

 

Tips for Utilizing Non-Credentialed Providers

If neither locum tenens nor reciprocal billing arrangements are a solution for your practice’s billing needs, don’t lose heart. There are some options to help fill the gaps as your providers gain their proper credentials. Here are a few quick ideas that might help your urgent care:

  • Always, always know your health plan contracts well— and understand the best way to bill for non-credentialed physicians (so no violation and potential lost contract occurs)
  • Have non-credentialed providers see only self-pay patients
  • Have non-credentialed providers do sports physicals, OccMed services, and other types of services that do not require credentialing
  • If commercial insurance allows some levels of staff to be non- credentialed, schedule more visits to those non-credentialed staff to help with workload until they receive their credentials
  • Work with patients who see a non-credentialed provider (out of network) so a payment plan or
  • some other option can be utilized
  • Start credentialing providers right away (even while in the interview phase) so by hire date their credentialing is in motion and ideally completed

A Last Word on Non-credentialed Provider Billing in Urgent Care

Non-credentialed provider billing will continue to grow as a topic and come under scrutiny. Due to the quick growth urgent care practices experience and turnover of physicians, it is important you know how to bill for non-credentialed providers when the need arises.

You must understand your contracts with health plans and what their billing policies are regarding non-credentialed providers to avoid any potential violations. Work closely with billers and credentialing teams to ensure your urgent care knows exactly how to bill claims for non-credentialed physician services.

 

References

  • Stantz, Renee (2011) Source. Billing for non- credentialed providers.
  • The Centers for Medicare and Medicaid Services (2014) Source. Medicare Claims Processing Manual.

 

Chapter 2

7 Common Missteps in Urgent Care Coding and Billing

Medical coding and billing is often viewed as its own world, separate from the practice of treating patients. But nothing could be further from the truth. Patient care and billing are intimately connected, and consequently, so is claim reimbursement.   Every   person in the claim creation process impacts revenue and the overall financial success of your practice.

Unfortunately, claims are often plagued by missteps because of the number of steps and people involved in the claim creation process. Reimbursement is the lifeblood of your clinic, so don’t  wait for problems to happen. Be proactive and look out for these common missteps in billing and coding to help your clinic receive the reimbursements you’ve earned.

 

Misstep #1

Bad (or No) Payer Contracts

Before workflow even begins, contracting is where issues can arise. If your clinic has poor or no  payer contracts,  this will be directly reflected in your clinic’s reimbursement.

Only when this is corrected will claims be processed and paid correctly.

Make sure you’re contracted with the payers in your area—preferably prior to opening your urgent care. If you wait to negotiate contracts, your clinic will not be able to accept insurance from patients in your area. While you can accept only cash-pay patients, your patient visits may stay low until more  contracts  are in place.

Advice: Hire a professional contracting expert who knows payers in your region. They will negotiate on your behalf, understand the fine print details, and know the best contracted rates for your region. Having a  versed  professional on your side will help you negotiate better rates—especially if you are a new urgent care.

 

Misstep #2

Poor Front Desk Processes

Patient registration has many steps, and errors can easily happen in this process. If a patient’s demographics, insurance numbers, and claim addresses aren’t entered correctly (or at all), submission will be delayed or the claim will  need to be re-submitted. An incorrect payer will often be selected by the front-desk based on past patient records.

A patient can unknowingly give incorrect insurance information if they are covered under multiple insurance plans. Poor front-desk policies can contribute to failures too. Have personnel ask “What’s your current insurance?” rather than the more general “Has anything changed since your last visit?” to avoid missed information.

Advice: Train front-desk staff to check insurance and periodically audit denied claims to see if you have a trend in incorrect information being entered during the registration process. Invest in a PM with integrated real-time insurance verification.

 

Misstep #3

Missing Valuable Charges

Incomplete documentation causes missed charges. This misstep can easily happen in the busyness of a patient visit, especially when instructions are communicated verbally. Common missed charges include labs, blood draws, administration of an injection, x-rays, and the reading of results.

In addition, providers can fail to document units of service (or drug dosage amounts). Quantity of  dispensed  drugs  need  to be noted accurately so the correct  charge can be stated on the claim. Poor documentation for procedures will cause delayed claim submission or missed reimbursement.

Advice: Teach providers to document commonly missed  charges  like   labs and injections. If your EHR has smart alerts, set these up to remind providers  of incomplete procedure documentation when locking charts. Have an easily reviewable list and common conversion table for drug dosage. Keep a log of all requested labs and drugs dispensed; double check these against claim charges.

 

Misstep #4

Using Wrong Codes and Ignoring Code Changes

Providers tend to get comfortable with their E/M code selection. Choosing a “just-right” Level 2 or 3  code  is  seen as a more prudent coding choice than choosing   higher   level    codes—even if documentation supports a higher code level. If providers consistently select lower code levels than services performed, your practice could be losing hundreds of dollars a day.

Incorrect or incomplete documentation habits lead to poor coding, both under- coding and up-coding (which often initiates audits). Providers will regularly focus directly on patient care, leaving code selection entirely in the hands of the coder.

While not incorrect in their focus, this mindset can contribute to loss of revenue and incomplete documentation.

The American Medical Association updates CPT codes annually; and the U.S. health system is transitioning from ICD-9 to  ICD-10  (adding  thousands  of codes which will impact practices and payers). If your coding team isn’t up on code changes and isn’t re- certifying for updates—your claims could be submitted with dated info, and you could be losing money.

Advice: Audit claim levels in your practice over several years and compare them to the industry norm. See if you’re potentially under- or up-coding based on benchmark patterns. If using an EHR, see if  providers  regularly  select a code other than what the system suggests or are selecting a single code level frequently. Make sure your coders are up to date on code changes.

 

Misstep #5

Choosing Incorrect (or Forgetting!) Code Modifiers

Code modifiers are an addendum to a selected CPT code, which help accurately describe to the insurance payer the type of services provided to the patient. Often, services don’t fit nicely into one CPT code—so modifiers can make the difference with explaining what exactly was provided to the patient. For example, if a patient had two distinct procedures performed during the same encounter on the same day, a modifier would be needed.

Code modifiers can easily be missed, used incorrectly, or abused. It’s also important to understand each payer’s requirements. Individual payers have varying levels of acceptance of certain modifiers, and the misuse of modifiers will cause claim denials.

Understanding HCPC levels is key to accurate reimbursement. HCPC Level 1 codes refer to CPT code charges. HCPC Level II codes are included for injectable drugs, medical equipment, or supplies provided in addition to treatment—such as splints or crutches. If you supply medical equipment, ensure you use correct code modifiers to prevent denials.

Advice: Ensure coders understand the proper use of modifiers. Run a  report on your most used CPT codes and corresponding modifiers and include these for easier selection on your super bill or in your EHR. Use code scrubbing software to automate repetitive modifier and code selections. Audit periodically to ensure modifiers are correctly correlated to provided services.

 

Misstep #6

Having Wrong Diagnosis to Procedure Mapping

A fast way to increase claim denials is to have a wrong diagnosis to procedure correlation. For example, if a patient has a laceration, you shouldn’t pair that procedure with a diagnosis of acute asthma.

Procedures should correspond directly with the diagnosis of the patient and be considered“reasonable and necessary” for treatment or preventative care.

It’s a coder’s responsibility to map the correct procedures with the relevant diagnosis code as documented. Knowing payer limitations and requirements (which change frequently) is essential to receive correct reimbursement—such as using NCDs or LCDs for Medicare patients.

Advice: Look at the correlation between diagnoses and procedures at your urgent care. Do they line up?  Make a list of the top diagnoses in your clinic and corresponding procedures to help educate your billers.  Always  know your payer’s requirements before claim submission. Utilize an automated coding tool to assign common diagnoses and procedure pairings.

 

Misstep #7

Not Following Up on Denied Claims or Writing Off Unpaid Charges Too Quickly

Many practices don’t have enough time or enough information to find a consistent pattern in claim denials. Sometimes billers don’t have time to audit  work— let alone look at problems with denials.

Looking at trends of denials with specific payers, providers, and similar diagnoses can give your clinic a more transparent, proactive approach to claim cleanliness.

After receiving claim payment, accurate payment posting is essential to reducing bad debt. Clinics often make the mistake of automatically writing off unpaid charges that can be appealed or corrected—and then resubmitted. If charges can be received from a payer with a few corrections,  it’s  worthwhile to take this additional step to ensure accurate revenue intake.

Advice: Avoid writing off bad debt for your practice by following up on denied claims. Find a pattern in your rejections and use them to help train staff on how to improve documentation.

 

Conclusion

While some urgent cares have  adopted a fee-for-service only model, most still rely on insurance payment.

As long as clinics depend on payers more than patient responsibility for reimbursement, claim coding and billing will be important for financial health. Consequently, making sure each step in the claim creation process is accurate and complete is vital to receiving timely and full reimbursement.

 

Chapter 3

Best Practices for Using Practice Management Software

Technology is everywhere in your urgent care. X-ray machines, lab equipment, monitoring devices—the list of technology  that  clinicians  use is diverse, and it evolves as new methods are introduced. Together with progression in medical knowledge, technology is a powerful tool for ensuring fast, more accurate diagnoses and treatments. The same holds true for your Practice Management software.

While technology isn’t a complete solution without  human  oversight, the use of healthcare advancements like Practice Management software is improved by following basic standards. To that end, software best practices help promote proper use—for the benefit of both clinic staff and patients.

Let’s examine  some  best  practices for using your urgent care’s Practice Management (PM) software during the patient check-in and check-out process.

 

Patient Check-in

Define Registration Steps before Using Software

Mapping out registration steps before using software will save you  time when using a PM. From greeting the patient, entering or finding them in the system,completingformsandinsurance, to adding patients to the queue—it’s important to clearly define steps for staff.

Defining steps outside the software for patient scenarios will help you easily, and more efficiently, translate steps into a digital PM workflow. A  process  map is a helpful tool for defining registration steps. This tool can help train new staff and remind current staff how to handle uncommon check-in scenarios.

For example, you may have fewer steps for a returning patient than a new patient, so be clear what steps can be eliminated for each visit type.

Also, define how staff should handle walk-in visits versus scheduled visits. Will specific personnel handle each visit type? Will you collect payment up front for cash-pay patients? If you have online check-in, how will patients be organized in the queue—and will you have policies in place for calling back patients for missing registration info?

 

Confirm Patient Form Needs and Avoid Duplicate Patients

You have standard forms for patient privacy and HIPAA compliance. But will you have HIE forms for patients to sign? And can each form be signed digitally so you can eliminate paper files in your office? Do you have a scan process for collecting driver’s license and insurance card info? Urgent care prides itself on speed of patient treatment, but make sure registration is collecting the correct patient information up front.

Always review and update pertinent patient information, like insurance and guarantor information. Regularly assess patient forms  and  info  needs,  and  as regulation or processes that need patient consent are added, import those forms into your system.

To avoid double entry of a patient in the PM, have a clear system look up to pull past patient information. For example, search date of birth and full name before adding a patient to your PM. Duplicate patients cause confusion and more work merging data, so have thorough search steps in place.

 

Verify Patient Insurance Immediately

Avoid calling patients after the visit to collect payment by verifying insurance upon check-in. While some PMs, like DocuTAP, include a real-time insurance verification button in the patient insurance screen, not all PMs have this time-saving option.

If your PM doesn’t have this option, make sure staff calls or checks the insurance payer’s portal during (or if possible, before) the patient visit to make sure insurance is valid.

Verifying insurance up front is important for your clinic to collect  both  the correct co-pay and/or charge the correct amount if the patient responsibility is higher—especially if insurance is expired, incorrect, or non-existent. Collecting moneyfrom patients is much easier while they are physically in the clinic; so collect money upfront instead of risking patient responsibility going to collections.

Also, it’s important to verify insurance for every visit in the PM, as contracts and insurance changes frequently. Your staff should also understand how to collect co-pays during global periods, depending on a patient’s needs  during a return visit (standard follow-up care versus health complication).

Payment policies should be clearly defined in your PM for staff. For example, if patients can’t pay a co-pay upfront, is that okay?

 

Have Clear Front-desk Staff Roles and Commit to a Training Program

Ensure successful registration practices in your PM by defining which people will collect what information in the software. If you have a larger clinic, or your reception process is unique, define roles and always have backup personnel trained. If you don’t have a triage nurse, train your front- desk staff on how to  recognize  critical  or life-threatening cases for immediate escalation—using both the PM and correct direct communication to providers.

An updated and defined training program for new hires is also an important software best practice for ensuring proper  PM  use.   Whether this is hands-on learning with practice patients, shadow training with a co- worker, or a designated training course, the more you teach your  staff  up  front, the better your intake  process will be. Traditionally, turnover happens more with front-desk positions, so a defined PM training program ensures knowledge gaps don’t happen when employees leave.

 

Set Up Employer Service Protocols

Offer occupational medicine or workers’ compensation services at your urgent care? If your software has configurable protocols for employer info, create unique protocols with procedures to be performed, special instructions, and forms—so you can quickly auto-populate employer info and requirements.

Having  employer requirements in your PM will not only save you time by eliminating manual entry, but it will also streamline communication between the front desk and clinical staff. If your PM has these options, take the time to set up data so you don’t have to add employer information every time or stress about remembering what details each employer requires.

 

Standardize Verbiage for Messages to Clinical Staff

If your  PM  and  EMR  are  integrated and have in-system messaging, set ground rules for staff correspondence. Nothing is more frustrating than miscommunication. In  an  urgent  care, it could be potentially dangerous  and, at the least, it could cost staff valuable time in trying to decipher needs. Give front-desk staff clear guidelines and a verbiage standard for sending messages to clinicians. Offer a mini-dictionary of acceptable verbiage for alerts and messages.

Also, outline acceptable  use  policies for what messages can be used for— and what type of information should be relayed in them versus a face-to-face conversation. Examples of clarifying digital communication could include tying messages to specific patient charts or implementing an acceptable use of text abbreviations. Messages sent from the PM, in addition to patient-specific instructions, can also include helpful reminders for providers—like alerts for drug seekers, allergy reminders, and immunization statuses.

 

Patient Check-out

Create a Check-out Process for Cash-pay (Self-pay)

After treatment, patients want to leave your clinic as quickly as possible. Help expedite the check-out process for cash- pay patients. Instead of paying a co-pay up front, cash-pay patients need to settle their balances upon leaving. Identifying cash-pay patients at check-in can help receptionists be prepared to collect payment at check-out.

Have a separate process to check-out these patients. You can designate a specific front-desk person for cash-pay patients or put a system in place to give these patients priority at check-out time. Have totals ready for the patient, and offer an easy-to-understand statement of charges. Payment plans and online payment options can also help you collect payments from your uninsured and cash-pay patients.

 

Have Credit Card Payment Integrated with PM Software

Save time by integrating credit-card processing with your PM. While most urgent cares accept credit card payment, not all clinics have this functionality built into the PM. You can prevent simple mistakes and time-consuming double- posting by adding this payment option to your PM.

Patient payments are more likely to be accurate when you streamline payment services with integrated credit-card processing. You can use credit-card processing to streamline both ends of patient visits, collecting co-pays at check-in and collecting patient payments at check-out, all with a swipe of a card. The time savings continue with quicker end-of-day routines for balancing the day’s tally of cash and checks.

 

Provide a Clear Visit Summary and Discharge Instructions

Have a clear process for providing patients with visit summaries and discharge instructions. In some cases, this can be handled by a discharge nurse or provider, while other clinics might choose to have a front-desk person provide this information. Visit summaries and discharge instructions should be easily printed from your PM. If you have a secure patient portal, you can also offer to send information electronically. Whomever provides instructions, offer the option of reading them aloud—and verifying where prescriptions were sent.

 

Ask Patients about Desired Follow-ups

A best practice for your  front  desk  is to note within your PM what steps the patient needs you to take next. After a visit, a patient may want your clinic to inform their primary care physician of the care they received from your staff. A patient might want to get a follow-up call or to have an appointment scheduled if they don’t have an established primary care physician.

Again, if you have a patient portal, patients can also request these follow- ups after they have left your clinic.  With   portal   messages,   a   patient can communicate directly with the provider—as well as request prescription refills, voice concerns about healing complications, and ask questions about at-home treatment.

 

Request Evaluation or Survey at Check-out

Most of the time, an unsatisfactory patient experience happens while the patient is in the clinic. To spot unhappy patients quickly and to save a valuable patient relationship, offer  evaluations or survey cards at check-out. Train front- desk staff to ask patients about their visit experience, and give them tools to remedy those visits.

Surveys can be provided as part of discharge instructions—just be sure to include a self-addressed stamped envelope. If you want to use an electronic method, you can send surveys through a patient portal, or by email if your survey doesn’t include any personal health information. Mailing a survey to the patient a week or so after the visit is another option.

No matter what method you use, keep   it quick at check-out, as your patient is focused on getting home.

 

Conclusion

Using a Practice Management software properly can help your staff streamline a patient’s check-in and check-out process. Take advantage of tools available within your PM to speed up your patient intake and discharge—and to provide a higher level of patient satisfaction. Remember, consistent process reviews will help your urgent care refine your current check-in and check-out steps.

 

Chapter 4

10 KPIs to Watch in Your Urgent Care

KPIs are the vital signs of your clinic. Similar to a patient exam, these metrics help tell the story of your urgent care’s overall financial health. Poor  KPIs  serve  as  warning   signs   of business issues that need to be addressed. With this data, owners are empowered to make wiser decisions regarding staffing, services offered, and process improvements.

While owners traditionally track  KPIs in an urgent care, all staff should understand why and how  the  KPIs are measured, and what actions affect each metric.

Here are ten of the most important KPIs to watch in your urgent care.

 

KPI #1

Average Revenue Per Visit

 

What it is and why it’s important:

The average revenue per visit is the total amount received per visit from both the patient and the payer. Average revenue shows actual payments received per visit. It also helps determine projected cash amounts.

 

What can affect it:

This number can be difficult to calculate accurately because it needs to be averaged over a set period of time, usually six months to one year (rolling average). Incomplete visits in A/R should be removed from this metric, along with bad debt write-offs.

Occupational medicine and workers’ compensation visits should be segmented and averaged separately, so they don’t skew the average revenue per visit for general urgent care visits. The mix of payer types and contracted rates affect this number.

 

How to calculate it:

(Total Payments Collected – Total Refunds) / Total Visits

Recommended: Calculate this over a set period of time each time.

 

 

KPI #2

E/M Code Distribution

 

What it is and why it’s important:

E/M code distribution shows the use of code levels by staff. E/M codes directly affect reimbursement amounts. Code levels 1 through 5 tell payers the level of visit complexity, and accordingly charges rendered.

 

What can affect it:

Documentation supports E/M code selection, so it’s essential for providers to enter all correct information for the appropriate code selection. Up-coding and under-coding can explain unnatural variations in E/M codes—leading to wider clinic revenue fluctuations. Chart audits (on a per provider basis) can pin-point coding and documentation performance needs.

The percentage of new versus established patient visits should be evaluated when reviewing E/M code distribution, as reimbursement per visit varies per patient type. Established patients traditionally have a higher code level, due to past documentation records.

 

How to calculate it:

Each E/M Code Level / Total Visits with an E/M Code

Recommended: Separate new and established visit types to create two E/M code distribution charts. A weighted average of E/M code  level can help you determine if your levels are trending in a certain direction over time for new and established visits.

 

 

KPI #3

Ancillary Revenue Per Visit

 

What it is and why it’s important:

Ancillary revenue  per visit  is  how much revenue you receive per visit for procedures and services. Urgent cares often have a contracted amount for an office visit E/M code with payers—so ancillaries are in addition to that amount. Ancillary charges can be labs, injections, x-rays, or medical equipment.

 

What can affect it:

Incomplete documentation of procedures cost an industry average of $25 per visit. Providers can forget to include procedure documentation and codes when tied to an ancillary service (such as a rapid strep test plus the charge for processing the lab result). Only visits with an E/M code should be considered, as these visits have procedures tied to the visit type.

 

How to calculate it:

Total Collections of CPT Code Range / Total Visits with CPT

 

 

KPI #4

Front Desk Collection Average

 

What it is and why it’s important:

Front desk collection rate is the percentage of collections gathered by the front desk from patients before they leave the clinic. A larger the percentage captured at the front desk is typically reflected in a higher percentage of overall collections per visit.

 

What can affect it:

Front desk procedures and personnel affect this metric. Enforcing the correct collection of co-pays at patient intake ensures higher percentage of patient payments in full.

Traditionally in urgent  care,  the policy  is to gather as much at time  of service as possible, since the patient is not as likely to be a repeat customer—or may not be insured.

Having real-time  insurance  verification in your software helps staff collect the correct amount. If patient is cash-pay, personnel should gather 100% at  time  of service.

 

How to calculate it:

Front Desk Collection Dollar Amount / Total Visits

 

 

KPI #5

Days in Accounts Receivable (A/R)

 

What is it and why it’s important:

Days in A/R is  the  amount  of  time your charges are sitting in accounts receivable. This is the revenue you  have yet to get paid for, divided by the average daily charges at your clinic. The lower your days in A/R, the quicker the turnaround with realized revenue.

 

What can affect it:

Payers and patient responsibility both affect this number. The cleanness of your claims during submission means a faster accepted claim and reimbursement. Fluctuations in days in A/R mean payer or claim issues are likely.

The goal for days in A/R is to keep day distribution steady and not to let more A/R slide to higher aging.

Days to bill (how long it takes to get your bills out) and days to pay (how long it takes a payer to pay) also affect this metric. Typical days in A/R for urgent care range from 20 to 40+ days.

 

How to calculate it:

Total Outstanding A/R / Average Daily Charges

Average Daily Charges = Total Gross Charges / Total Visits

 

Recommended: Use last 90 to 120 days of charges as an average to remove seasonal fluctuations. Also review total days in A/R versus insurance-only days in A/R.

 

 

KPI #6

Percentage of Accounts Receivable Over 120 Days

 

What it is and why it’s important:

This metric is the percentage of A/R being held for over 120 days. The longer your  A/R   isn’t   collected   (in 90 to 120+ days) the more likely it is you have serious collection issues— and lower overall reimbursement  rates. The goal is to have the smallest percentage possible fall into this older aging bucket. Split your A/R into categories of insurance, patient, and employer—and set goals for how much A/R you’d like in each aging segment.

 

What can affect it:

Offenders for insurance delays could be payer contracts, provider credentialing, front desk procedures, or not completing A/R fast enough.

You can keep your patient A/R from aging to 120+ days by sending unpaid balances to collections at the 90-day mark.

 

How to calculate it:

Total A/R Aged Over 120 Days / Total A/R

 

 

KPI #7

Days to Bill

 

What it is and why it’s important:

Days to bill is how long it takes your billing team to get claims submitted. Faster days to bill  means  fewer  days  in A/R and faster reimbursement from insurance and patients. However, faster days to bill is not worth causing claim quality to suffer if you increase claim rejections and therefore, days in A/R.

 

What can affect it:

Several items can slow days to bill. They include providers not locking patient charts, front desk errors, slow coding teams, EMR system not set-up to have claims prepared daily, or bad processes for following up on unsent claims.

 

How to calculate it:

Number of days between visit date and claim date to the first payer

Recommended: Calculate only for visits with insurance claims.

 

 

KPI #8

Days to Pay

 

What it is and why it’s important:

Days to pay is the amount of time it takes a payer to pay a claim. Quicker reimbursement means fewer days in A/R and faster revenue realized.

 

What can affect it:

This number will vary based on payer types and will be affected by how clean your claims are. Contracts with payers generally define days to pay—and appeals for claims can be submitted by billing teams if the claim is rejected or not submitted on time.

Ranges for days to pay depend on payer and claim practices, but typically fall in a 7 to 30 day range.

 

How to calculate it:

Number of days between the date when claim is sent and date of first payment received from insurance

Recommended: Calculate only for visits with insurance claims. Break days to pay down by payer. This can identify payers who take longer to pay—so you can pin-point delays and inquire about reasons why.

 

 

KPI #9

Visits Per Clinic Per Day

 

What it is and why it’s important:

Even with the best payer contract rates, it doesn’t matter if you don’t have any patients coming through the door. You won’t reach a profit without adequate patient volume. An urgent care business plan should designate break-even and profit points tied to visits per day.

 

What can affect it:

The age and location of the clinic affects this number. Newer clinics  slowly  build a patient base, while established clinics have a solid base with repeat customers and a reputation of service to rely on. Marketing and community partnerships can also increase this metric. Seasonality will often increase or decrease visits.

 

How to calculate it:

Total Patient Visits / Total Number of Business Days

Recommended: Calculate over a set time period—generally a week or month. Segment numbers by clinic if you have multiple locations.

 

 

KPI #10

Door-to-door Time

 

This is the amount of time it takes from the moment a patient enters your clinic to when they leave. In urgent care, lower door-to-door times increase the number of patients you can see. The more efficient the visit time, the more revenue made.

What can affect it:

Complexity of visit, staff response within the clinic, and poor workflows can affect this number. Typical door-to- door times in urgent care range from 20 to 70 minutes, well under national emergency room averages.

 

How to calculate it:

Total Door-to-Door Time for All Visits / Total Visits

Recommended: Calculate over a set time period— generally a week or month. Segment numbers by clinic if you have multiple locations.

 

Conclusion

Use KPIs to understand your organization’s health. Having set goals for your clinic is essential for success, along with establishing a baseline of data for comparison. Examining data over periods of time gives your clinic a well-rounded picture of performance.

Consistent data review keeps  you  aware of trends and potential issues.  An invaluable asset to your clinic is a reporting tool that lets you pull  real- time reports, find clinic trends, and spot trouble areas quickly. Better yet  is  if this  tool   includes   benchmarks   that let you compare your results directly against other urgent cares, regionally and nationally.

Data interpretation  requires   looking at the entire scope of your clinic’s performance  to  find  correct   cause and effect. Assumptions and incorrect comparisons can result in poor reactions and business decisions. KPIs empower better decision making for urgent care owners—but only if you know how to calculate them, track them, and adjust processes to improve results.

 

Summary

To be successful and compliant, urgent care clinics must count on the accuracy of every claim. Understanding the differences in coding for non-credentialed providers, watching for common errors with regular audits, instituting best practices, and staying on top of important key performance indicators are big factors in supporting your success.

Partner with DocuTAP to streamline your billing processes. Learn more.

 

TAKE THE NEXT STEP

Faster charting.
More revenue.
Shorter wait times.

Because we’re solely focused on urgent care, we eat and breathe efficiency. We think about software solutions the way you think about on-demand care. It should begin with a goal, remove obstacles, and make life better.