U.S. imaging centers will be facing reimbursement reductions in their revenue stream in 2007. For those facilities with a substantial mix of Medicare beneficiaries, this reduction will be significant. Even those sites that cater to a largely private-payor demographic are likely to see the bottom line suffer, as insurers will aggressively attempt to tie their imaging service reimbursement to the Centers for Medicare and Medicaid (CMS) payment rates.
Although the road ahead appears daunting, there are steps that administrators can take to tune and maximize their imaging center's revenue cycle now. By implementing these processes over the next few months, a practice stands a better chance of meeting the challenges of the coming year.
According to Patricia Kroken, a principal in Healthcare Resource Providers, an Albuquerque, NM-based radiology business consulting firm, the imaging center revenue cycle has four elements:
- Patient registration/scheduling
- Billable service provided
- Billing process
- Reimbursement
"I'm a firm believer in taking a holistic view of this cycle," said Kroken in a presentation at the American Healthcare Radiology Administrators (AHRA) annual meeting earlier this month in Las Vegas. "It's not something where you can focus on one area and have everything go smoothly. At any given time, one of these areas will be up for grabs -- so what you want to do is control as much of the process as you can, because something is always going to be happening beyond your control."
Patient registration/scheduling
"If we look at the imaging center revenue cycle, it all starts with patient registration and scheduling," Kroken said.
One of the best methods an administrator can utilize to guarantee consistency is to standardize and document the facility's processes for scheduling and registration, according to Kroken. Although referring physicians vary in the way they schedule their patients, there needs to be a solid baseline methodology for staff that allows flexibility for variations, she said.
Sufficient resources need to be available for scheduling personnel, including contact directories and contract requirements for each of the group's payors. These resources need to be in one area, preferably a notebook at each scheduler's work area.
"Accuracy of their information and/or errors will impact every single other area of the revenue cycle," Kroken said. "So if it screws up on the front end, the ripple effect from then on is going to keep it screwed up for the entire process."
Therefore, she said, it is very important that these personnel receive ongoing monitoring and training. To enhance this, she recommends an emphasis on cross-training for front-end staff, so that employees can be flexible in their job positions and can meet the challenges of busy and slack times throughout the course of a day.
In addition, wherever possible, a practice should try to automate as many common processes as it can, such as scanning insurance cards. The use of technology reduces the number of full-time equivalent (FTE) employees needed to run the practice and can eliminate duplication of effort, providing a single entry point of information for verification, workflow management, and billing and collections.
"The guarding caveat with that is that the process better work pretty well first, or the technology may not fix it," she said.
Billable service provided
Ensure that your processes for providing imaging service are streamlined. This means that paperwork is ready when the patient arrives and that information is in the RIS or a folder prior to the exam being conducted. The technologist is notified, promptly, of the patient's status, the patient is escorted to a changing room, and the equipment is available.
"That means, once we've got the patient in there, we want to get them taken care of and get them out of there so we can get paid for the work we do," Kroken said.
One of the limitations to efficient scheduling during this period in the cycle is inconsistent imaging protocols. Generally, variations can be traced to the radiologist who is covering that modality at the time the exam is conducted. Protocol variations require extra time, Kroken said, and increase the possibility for error because the staff must memorize variances by radiologist. In addition, they can change scheduling blocks and reduce the scheduling inventory.
At this point, protocol variances become a matter of economics. To maximize imaging services, a practice's radiologists should agree on standard, set protocols to which they will all abide.
Technologist productivity during this period of the cycle is the key element to maintaining productivity and profitability, Kroken said. As such, administrators should look to remove as many nonessential tasks as possible for their technologists. These include escorting the patient, tearing down or preparing the exam room, processing paperwork or films, and entering information into the RIS. Most often, these chores can be handled by a lower-priced support person.
"Looking at it from a manufacturing standpoint, there are two people that need to be really efficient: one's the radiologist, the second is the technologist," Kroken said. "You want to use them doing what it is that they are specially trained to do and not having them do a lot of extra stuff that gets in the way -- it's very expensive extra stuff."
Billing process
In the ideal world, Kroken said, a practice would enter the patient information, an insurance claim would be submitted, and the group would be paid.
"Occasionally this even occurs, but not frequently," Kroken observed.
In reality, a percentage of claims are denied for an error -- real or not. The denial is then assigned for follow-up and research, and the claim is corrected and resubmitted. If it is done in a timely manner, the practice will eventually receive payment.
"It's more expensive to do this correction piece than it is to have trained your people up front to get the right information," Kroken said.
It's imperative that the superbill or electronic record contain the insurance/guarantor information, the patient identification including insurance plan numbers, the referring physician identification, the documentation of processes performed, and a signed waiver to bill insurance. In addition, prior authorization, advanced beneficiary notice (ABN), the written order for the procedure, and the radiology report have to be elements of the data acquisition process for all claims filing.
If all this information is collected and correctly submitted for each and every claim, chances are claim denial rates will be minimized, Kroken noted.
Charge entry patterns should be monitored on both a daily and weekly basis, she said. This provides a predictor of cash-flow functions, and helps identify and address backlogs before they impact claims submission and cash flow.
Claims technology is an important tool that a practice should adopt. Electronic claims "scrubbers" will improve clean claims by reviewing a claim prior to submission and kicking it back for review if the information is inconsistent or missing.
Filing electronically will enable the practice to take advantage of prompt payment or denial, generally within four to 10 business days, Kroken said. In addition, if a claim was denied, many payors provide options to follow up or correct certain claims criteria online, which greatly speeds up a practice's denial process, she noted.
Reimbursement
If available from the payor, Kroken recommended that radiology groups take advantage of HIPAA 835 transactions. This allows for the payment to be sent to the practice's account and for documentation to be sent to its business office for posting. In some cases, automated posting options are available in newer systems, she said.
Not getting reimbursed for services performed is a problem that all groups face in their practice. For payors, it is crucial that administrators establish a standardized appeals process as part of their denial management strategy and then monitoring its results. This allows a practice to correct the cause of the denial and prevent it from occurring again by making needed changes to coding documentation, the radiologist's dictation, or completely and accurately creating the claim prior to submission.
Because many private payor plans have high deductible options, a practice may want to collect the deductible from the patient at the time of service.
"If you've got somebody with a $1,000 or $5,000 deductible showing up at your front desk, you've got that deductible to fulfill before you're going to see your money," Kroken said.
It's become more important to have good private-pay follow-up on the front end, so that you are able to collect from the patient what they owe in these circumstances, which may well be the entire cost of the study, she noted.
As patient payment responsibility becomes more common, Kroken suggested that a practice may want to investigate payment plans for large balances, credit and debit card transaction capabilities, online payment options, and even offering discounts for cash payments in full. The philosophy, she said, should be to assist the patient to find a way to pay the bill.
"The big mantra for the revenue cycle is to monitor these things, communicate like crazy, and train your people," Kroken said.
By Jonathan S. Batchelor
AuntMinnie.com staff writer
August 25, 2006
Related Reading
Increase image reimbursement with a designated coder, August 7, 2006
DRA cuts affect more than imaging providers, August 2, 2006
Improve what? Finding a process to improve, July 27, 2006
Strategic planning considerations and the Deficit Reduction Act of 2005, June 27, 2006
DRA 2005 in practice: Where the rubber meets the road, April 27, 2006
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