Being the Best Billing/ Coding Manager
Tips to Maximize Insurance Reimbursement
1. Ensure that all services and products are properly coded
2. Patient revenue and collections 3. Insurance verification 4. Claim management 5. Denial/ rejection resolution and prevention 6. Establish clear revenue cycle procedures 7. Reviewing fee schedule yearly 8. Medical and vision services 9. Review provider reference manuals 10. Track performance 11. Outsourcing 12. Review insurance contracts
Billing KPIs
Monitoring the key performance indicators (KPIs) of the revenue cycle provides insight into billing data, influencing process improvements that lead to an increase in captured revenue. 6 Key RCM KPIs to monitor :
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1.A/R percentage over 61 days
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Insurance Aging
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Total A/R % of 61-121+ Days
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target = 12-15%
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Total A/R % over 121+ Days Target = 3%
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Patient Aging
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Total A/R % of 61-121+ Days
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target = 12-15%
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Total A/R % over 121+ Days Target = 0%
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When reviewing the patient aging, watch for repeat missed opportunities to collect during the visit. Patient Aging Review: •Monitor the number of small balances of $50.00 and under •Missed Copayments •Uncollected non-covered items (refractions) •Uncollected balances on eyeglasses or contact lenses •Look for preventable patterns
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How to calculate: Take the dollar amount of the total accounts receivable 61 to 121+ days ($14,803.80) / Total outstanding insurance claims 0 -121+ days X 100 = % $73,574.00 / 210,000 X 100 = 35%
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KPI measures: • The overall effectiveness and efficiency of the billing operations. • This percentage may vary depending on the mix of payors • A higher percentage can signify delays in submitting claims • Increase in denials or first-pass rejections • Delays in applying payments or poor collection processes.
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2.A/R percentage over 121 days
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Target= 5% or less.
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KPI measures: • Whether patients and insurers are paying timely. • A/R over 121 days, greater than 5% can be an indication of claim denials and follow-up issues • Inefficient patient collections process.
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How to calculate: Take the dollar amount of the total receivable (net credits) greater than 121 + days / Total outstanding A/R for 0 -121+ days = % $35,730 / 210,000 X 100= 17%
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3.Days in A/R
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number of days it takes to resolve an encounter to zero balance.
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target = 28 days or less.
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How to calculate: 1) Total monthly receipts / 30 days = Average daily revenue $140,000.00 / 30 = $4667.00 2) Total accounts receivable/average daily revenue = Days in A/R $242,900 / $4667.00 = 52 Days in A/R
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KPI measures: • On average the number of days it takes for the practice to be paid. • Indication of overall revenue cycle performance and can identify performance issues impacting cash flow. • High-performing practices may collect between 20 and 25 days.
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4.Gross collection rate
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% of revenue collected on balance owed to the practice.
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target = 60-75%
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this percentgae will vary depending on he contracted payers and without percentage.
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How to Calculate: Total monthly payments / Total monthly charges X 100 = GCR percentage (for a specific time period) $140,000 / $225,000 X 100 = 62%
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KPI measures: • An indication of how well the practice is doing at collections. • A high gross collection rate may be an indication your fees are close to the payer’s rates. • Each practice will have a slightly different GCR since each set a unique fee schedule and contract with various payers. • Monitored for consistency rather than an exact benchmark
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5.Net collection rate
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Target Benchmark: 95% or greater
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How to calculate: Total payments (net any credits) / by charges - contractual adjustments X 100 (for a specific timeframe, for example Oct – Dec. 2023) $675,000 (billed charges) - $270,000 (CO adjustment, 40%) = $405,000 expected in collected revenue. Actual revenue collected $385,000 / $405,000 = 95% (Average Collection Rate is about 95% or higher)
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KPI measures: • Shows the percentage captured of the allowed reimbursement after the practice’s contractual obligations have been adjusted. • The contractual adjustment amount will vary by practice, depending on practice fees and the mix of payors.
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6.Denial Rate
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Common Reasons for Denials: • Unverified Insurance Coverage • Incorrect patient identifier Information • Coverage terminated • Benefits unavailable • No referral or prior authorization on file • Services excluded or non-covered • Incorrect plan billed / COB • Missing or invalid CPT or HCPCS codes • Missing or improper use of modifier(s) • Missing/lacks information • Timely filing • Lapse in credentialing (Medicare, Medicaid, Tricare)
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Reports Needed:
• Insurance Aging Report
• Patient Aging Report
• Gross charges for the month/quarter
• Gross revenue for the month/quarter
