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The Biggest Challenge for Out-of-Network Plastic Surgeons (And How You Can Turn It Around)

Being an out-of-network plastic surgeon in the US has its perks—but let’s be honest, it comes with its fair share of challenges too. The primary hurdle? Patient affordability. Convincing patients to pay out-of-pocket for procedures when insurance isn’t covering the tab can feel like trying to sell snow in a snowstorm. But if you’re prepared, you can overcome this obstacle and turn “out-of-network” into a competitive advantage.

Here’s a deep-dive into the roadblocks and how you can tackle them head-on—with a scalpel-like precision.

1. High Out-of-Pocket Costs for Patients

For most patients, hearing “that’ll be $10,000 upfront” can feel like a gut punch.

  • Common Scenario: A patient is eager for a rhinoplasty. They’ve saved up, but the minute they learn their insurance won’t chip in, they hesitate.
  • Reality Check: Elective procedures like breast augmentations, facelifts, and liposuction aren’t covered by insurance at all. Even reconstructive surgeries often require pre-approval and lots of documentation.

Solution:

Make it as easy as possible for patients to understand costs. Offer bundled or transparent pricing (e.g., “Here’s exactly what $8,000 includes”) and emphasize the value of your expertise.

2. Competition from “Covered” Surgeons

Patients love a deal. When in-network surgeons can say, “This surgery is 80% covered by insurance,” it’s a tough act to follow. But here’s the thing—not every patient is looking for a bargain.

Flip the Script:

Highlight your strengths.

  • Do you have advanced certifications?
  • A proven track record of outstanding results?
  • World-class before-and-after photos?

When you position yourself as the best choice (not the cheapest), you’ll start attracting patients who value quality over cost.

3. Administrative Hurdles & Paperwork Woes

Insurance companies don’t make life easy for out-of-network providers. You’ve probably faced these headaches before:

  • Claim Denials. A medically necessary skin cancer reconstruction gets rejected due to “inadequate documentation.”
  • Pre-approval Speed Bumps. Breast reduction surgery for a patient with chronic back pain gets delayed for weeks.

How to Navigate This:

  • Dedicate a portion of your team to handle insurance negotiations. Your staff can guide patients through reimbursement requests or help with proper coding.
  • Provide templates for appeals. For example, draft detailed letters patients can submit for medically necessary claims.

One plastic surgeon in New York shared how they resolved this problem by hiring a part-time “insurance advocate” dedicated solely to liaising between their practice, insurers, and patients. “It cut down patient frustration by at least 30%,” they said.

4. A Smaller Pool of Potential Patients

Being out-of-network limits your audience. Many patients can’t afford procedures without insurance, shrinking your funnel of opportunities. But here’s where you can thrive.

Find Your Niche:

One Dallas-based surgeon mastered the art of “mommy makeovers” and marketed exclusively to affluent moms through Instagram, where they showcased unbelievable transformations. Finding a niche turns potential scarcity into razor-sharp focus, attracting the exact clients you want.

5. Pressure to Offer Financing Options

“We offer financing plans!” You’ve probably seen competitors promote this as their go-to solution. Truth is, patients expect it. If you haven’t explored partnerships with companies like CareCredit or Alphaeon, now’s the time.

Pro Tip:

Bundle financing plans with other perks, such as post-op care packages or complimentary consultations. Showing you’ve thought about the patient experience beyond the wallet builds loyalty.

6. The “Too Expensive” Perception

Some patients jump to the conclusion that out-of-network equals unaffordable and unnecessary. Even worse, they assume you’re only for the ultra-rich.

How to Tackle It:

  • Leverage social proof. Feature testimonials and success stories from patients who believed the extra cost was worth it.
  • Share relatable case studies. For example, “Meet Jane, a golfer who couldn’t compete due to injury. We repaired her torn cartilage, which wasn’t covered by insurance, but now she’s back on the course pain-free.”

Why Being Out-of-Network CAN Be an Advantage

Sure, it’s not all sunshine and roses, but being out-of-network offers unique benefits for surgeons who know how to position themselves.

Here’s why it might actually work in your favor:

  • Full Autonomy. Forget rigid insurance policies that dictate what procedures you can perform or how much you’ll get reimbursed.
  • Patient-First Decisions. You control the patient experience without cutting corners just to fit insurer guidelines.
  • Higher Profit Margins. When payments come directly from patients, you dodge the time and effort spent chasing down insurers for reimbursements.

How to Build Success as an Out-of-Network Surgeon

Successful out-of-network plastic surgeons rely on these strategies to thrive:

  • Hybrid Models. Offer insurance-based options for reconstructive cases while keeping elective procedures strictly self-pay.
  • Brilliant Marketing. Invest in showcasing your specialty. Results-driven photos and patient testimonials are worth their weight in gold.
  • Showcase Value. From world-class customer service to state-of-the-art technology, remind patients what makes you stand out.

Real-Life Case Study

Dr. Michaels in LA decided to specialize in out-of-network cosmetic surgeries. He invested in world-class imaging technology to offer 3D previews of post-surgery transformations. Patients were willing to pay a premium because they felt confident in the results they’d get.

Another standout example is Dr. Rivera in Miami, who packages her services as “luxury experiences.” Her office provides spa-like amenities and VIP-level care, creating an atmosphere that justifies her prices.

The Bottom Line

Yes, being out of network comes with hurdles—but it also opens the door to immense opportunities. It’s about catering to the right audience, showcasing your value, and standing firm in the premium quality of your services.

Remember, it’s not about being “affordable” for everyone. It’s about being remarkable and unforgettable for the right people.

If you’re looking for guidance on fine-tuning your out-of-network strategy or transitioning entirely to a cash-based practice, we’re here to help. Let’s talk!

What’s Next? (hint: Bill with out-of-network benefits)

Stay tuned for our next blog, where we’ll explore the intricate process of how surgeons can bill insurances for patients with out-of-network benefits. We’ll break down the steps, discuss the challenges commonly faced, and provide insights to help you navigate this complex system with confidence. Whether you’re just starting or seeking to optimize your approach, this upcoming discussion will provide the clarity you need. Don’t miss it!

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Payment Revolution in Healthcare Find Out the Magic Behind EFT ERA Enrollment 

If you’ve spent enough time managing healthcare payments, you know it’s not all sunshine and rainbows. Paper checks get lost, reimbursement delays are a common headache, and the manual labor involved can drive anyone up the wall. But what if there was a way to sprinkle a little magic over these issues? Enter EFT (Electronic Funds Transfer) and ERA (Electronic Remittance Advice) enrollment—a modern-day solution for seamless payments to healthcare providers. 

In this guide, we’ll unravel the mysteries of EFT/ERA enrollment, highlighting its importance, benefits, and how you can get onboard this payment revolution. Whether you’re a healthcare provider, medical billing professional, or healthcare administrator, this post is designed to offer valuable insights and practical tips to streamline your billing processes. 

Understanding the Dynamics EFT and ERA Explained 

Imagine a world where payments flow directly into your account without fuss, and detailed transactional information is just a click away. That’s the world of EFT and ERA. 

EFT is your trusted courier, ensuring that funds move seamlessly from payer to provider. No stamps required. Meanwhile, ERA is like the Rosetta Stone for your payments. It decodes complex payment information into a format you can easily digest. 

These two tools are reshaping the payment landscape in healthcare, offering a streamlined approach that’s faster, more efficient, and remarkably secure. 

The Perks Why EFT ERA Enrollment is a Game Changer 

Why should you consider enrolling in EFT/ERA? Hold onto your hats because the benefits are substantial: 

  • Speed and Efficiency: Faster transactions mean quicker access to funds. No more waiting for checks! 
  • Accuracy in Accounting: With ERAs, you get detailed payment information, reducing errors in financial documentation. 
  • Cost Savings: Less paper, less hassle. Enjoy reduced administrative costs as you wave goodbye to traditional check handling. 
  • Enhanced Security: EFTs and ERAs are fortified with security measures to protect sensitive financial information. 

Enrolling in EFT/ERA isn’t just a good idea; it’s a smart business move that can save both time and resources. 

Enrolling in EFT ERA A Step-by-Step Guide 

Ready to sign up? Here’s how you can make the smooth transition to EFT/ERA: 

Understanding the Enrollment Process 

The first step in your EFT/ERA enrollment is understanding the process. It typically involves: 

  • Choosing a participating payer or clearinghouse 
  • Completing an enrollment form 
  • Verifying bank account information for EFT 
  • Designating a contact person for communications 

Required Information and Documents 

Gathering the right documents in advance can save you from unnecessary back-and-forth. Typically, you’ll need: 

  • Banking details for EFT (such as account and routing numbers) 
  • Tax Identification Number (TIN) 
  • National Provider Identifier (NPI) 
  • Contact information for your finance or billing department 

Common Pitfalls to Avoid 

Even the best-laid plans can go awry. Avoid these common pitfalls: 

  • Incorrect bank details leading to rejected EFTs 
  • Delays due to incomplete forms 
  • Communication breakdowns between departments 

It’s all about dotting your i’s and crossing your t’s—attention to detail goes a long way. 

Leveraging Third-Party Intermediaries Pros and Cons 

In the quest for a seamless transition to EFT/ERA, enlisting the help of third-party intermediaries can be a strategic choice. These companies specialize in bridging the gap between healthcare providers and payers, offering expertise to streamline the enrollment process and manage transactions effectively. However, as with any business decision, utilizing an intermediary comes with its own set of advantages and drawbacks. 

Pros: 

  • Expert Guidance: Third-party intermediaries are well-versed in the intricacies of EFT/ERA enrollment and compliance, providing valuable insights and assistance to ensure successful implementation. 
  • Time Savings: By handling the administrative legwork, these intermediaries can save healthcare providers significant time, allowing them to focus on their core responsibilities. 
  • Enhanced Accuracy: With experience in processing payments and managing documentation, intermediaries can help reduce errors that might occur if managed in-house. 
  • Scalability: As your practice grows, an intermediary can scale their services to accommodate increased transaction volumes efficiently. 

Cons: 

  • Cost: Engaging a third-party service often involves fees, which could impact the overall cost savings of transitioning to EFT/ERA. 
  • Reliance on External Parties: Relying on an intermediary means placing trust in an external entity to manage sensitive financial and billing information. 
  • Potential Delays: While intermediaries work to streamline processes, any miscommunication or errors on their part can result in delays, much like pitfalls that occur in direct enrollment. 
  • Vendor Lock-In: Once a provider partners with a specific intermediary, switching to another service or back to self-management could present challenges and cause disruptions.  

Opting to work with a third-party intermediary involves weighing these factors carefully and deciding based on the specific needs and capacities of your healthcare operation. 

Examples of Third-Party Intermediaries 

Choosing the right third-party intermediary is crucial for a successful EFT/ERA transition. Here are a few reputable companies that provide these services: 

  • Zelis Healthcare: Known for its comprehensive suite of payment solutions, Zelis Healthcare offers integrated payment services that enhance speed, accuracy, and transparency. 
  • Change Healthcare: This intermediary provides a robust platform with a focus on maximizing efficiency and improving payment processes, catering to both large health systems and smaller practices. 
  • Availity: Availity specializes in provider engagement and billing efficiency, offering solutions that streamline administrative tasks and improve financial transactions. 
  • Emdeon: With a strong emphasis on connectivity and healthcare payment integration, Emdeon helps manage complex billing processes with ease. 

Selecting an intermediary like these can provide the support and technology needed to navigate the complexities of EFT/ERA enrollment, giving healthcare providers peace of mind and operational efficiency. 

Tackling Enrollment Challenges 

Change can be daunting, but don’t worry. Here’s how to tackle some common hurdles: 

Addressing Resistance and Misconceptions 

Some individuals may be hesitant to switch from paper checks to digital payments. To address common misconceptions, highlight the security features, cost savings, and increased efficiency of EFT/ERA. 

Navigating Technical and Administrative Hurdles 

Technical hiccups and administrative red tape can be frustrating. Consider these strategies: 

  • Collaborate closely with IT where applicable to ensure systems are compatible. 
  • Foster open communication with payers and clearinghouses to resolve issues promptly. 
  • Conduct training sessions for staff to familiarize them with the new processes. 

How EFT ERA Elevates the Payment Game 

With EFT/ERA, the healthcare payment landscape is transforming. Here’s how it’s making waves: 

Enhancing Efficiency and Accuracy 

EFT/ERA improves the speed and accuracy of payments. Billing becomes a breeze, and financial records are more precise than ever before. 

Boosting Security and Compliance 

Data breaches are a real concern, but EFT and ERA come with robust security protocols. Plus, they help you stay compliant with industry regulations. 

Slashing Administrative Costs 

With fewer papers to shuffle and fewer checks to handle, administrative costs shrink significantly. That’s more budget for the things that really matter. 

Real-Life Success Stories 

Here’s where the rubber meets the road. Many providers have already embraced EFT/ERA with great success: 

  • Dr. Smith’s Clinic saw payment processing times drop from 30 days to just 7. 
  • HealthCo Group reported a 20% reduction in administrative costs after switching to electronic payments. 
  • The Care Center improved its billing accuracy by implementing ERA across all departments. 

These examples illustrate how EFT/ERA can transform your organization’s financial operations. 

What Lies Ahead – The Future of EFT ERA in Healthcare 

The world of healthcare payments is evolving, and staying ahead of trends is crucial. Here’s what’s on the horizon: 

AI and Machine Learning Integration 

Artificial Intelligence and machine learning are poised to further enhance EFT/ERA processes, offering predictive insights and automated reconciliation. 

Blockchain for Unmatched Security 

Blockchain technology may soon bring unparalleled security and transparency to healthcare payments, building trust and reliability. 

Real-Time Transactions 

Imagine payments processed in real-time. The future of EFT/ERA could very well include seamless transactions that happen instantly. 

Wrapping It Up: Take Action Today 

In a world where time is money, EFT/ERA enrollment offers healthcare providers a golden opportunity to streamline their payment processes. By understanding the enrollment process, tackling common challenges, and recognizing the benefits, you’re well on your way to a more efficient and profitable operation. 

Don’t wait. Take action today. Investigate your options for EFT/ERA enrollment and bring your payment processes into the modern age. For more information and support, consider reaching out to industry experts who can guide you through the transition smoothly. 

Ready to revolutionize your payment systems? Say goodbye to the old ways and hello to the future of healthcare finance with EFT/ERA enrollment. 

How to Recover Money from Patients When Out-of-Network Insurance Sends Checks Directly to Patients

Let’s paint a scenario: You’re a healthcare provider out of network with an insurance company. Your patient has out-of-network benefits, but here’s the kicker—the insurance company sends the check directly to the patient. Frustrating, right? Don’t worry, we’ve got a guide to help you navigate this tricky situation and recover the money owed to you.

Step-by-Step Process for Recovering Money from Patients

1. Verify Insurance Coverage

Before you even start treatment, verify that the patient has out-of-network benefits. Understand the coverage details, including deductibles and co-insurance. This knowledge is crucial in setting clear expectations.

2. Transparent Communication

Have an open conversation with the patient about their financial responsibility. Explain what the insurance company covers and what they will owe directly. Trust me, clear communication here can save a lot of headaches later.

3. Documentation

Keep meticulous records of the treatment provided, the amount owed, and any communication with the patient or insurance company regarding payment. Documentation is your best friend.

4. Billing the Insurance Company

Submit a claim to the patient’s insurance company. Make it clear to the patient that you are an out-of-network provider and list the services provided. This ensures there are no surprises on either end.

5. Check for Errors

Regularly check the status of your claim. Ensure there are no errors and that it is moving through the payment process smoothly.

6. Check Mailing Address

If the insurance company sends the payment directly to the patient, make sure they have your correct billing address. This way, the patient knows where to forward the check.

7. Follow Up with Patient

Once you confirm via the insurance portal or clearinghouse that the check has been sent to the patient, follow up promptly. Request payment and offer multiple options for how they can make the payment—online, over the phone, or by mail. Flexibility can make a big difference.

8. Payment Plans

If the patient struggles to pay the full amount out-of-pocket, discuss setting up a payment plan. Find a solution that works for both parties. Compassion coupled with persistence can go a long way. Payment plans are not offered when the insurance company has sent the payment to the patient.

9. Legal Options

If all else fails and the patient does not make arrangements to pay, consult with a legal advisor. Explore your options but remember to keep this as the last resort.

10. Persistence

Maintain open lines of communication and be persistent in your efforts to recover the funds. Follow up regularly and keep the conversation going.

Real-World Scenarios to Illustrate the Process

Scenario 1:

A patient with out-of-network benefits undergoes a session with a therapist. The insurance company processes the claim and sends a check directly to the patient. The patient promptly informs the therapist. The therapist follows up with the patient, requesting to forward the check or bring it in person. The patient complies, and the therapist processes the check.

Scenario 2:

In another instance, a patient receives a check from their insurance company and forgets to inform the provider. After a month, the provider reaches out for payment, and the patient realizes they received the check but forgot to forward it. The patient immediately sends the check to the provider, who then processes it.

These scenarios highlight the importance of clear communication, documentation, and persistent follow-up to ensure timely recovery of owed funds.

Final Thoughts

Recovering money from patients when out of network can be challenging but not insurmountable. By following these steps and maintaining a proactive approach, healthcare providers, medical billing staff, and practice managers can navigate these tricky waters effectively. Your persistence, coupled with clear communication and thorough documentation, will ensure you recover the funds you’re due.

Got any other tips or experiences to share? We’d love to hear them in the comments below. And if you found this guide helpful, why not share it with your colleagues?

Stay persistent and stay informed!

Patients Inundated with Too Many Appointment Reminders

Patients inundated with too many appointment reminders face a myriad of challenges that can greatly impact their overall healthcare experience. This article delves into the various aspects of this issue, ranging from the consequences of excessive reminders to the need for customized appointment reminder systems that cater to patient preferences. Understanding these factors is crucial for healthcare providers as they strive to deliver high-quality care while remaining mindful of patient needs and preferences.

The impact of excessive appointment reminders on patient experience

Excessive appointment reminders can have a significant negative impact on the overall patient experience. The constant influx of reminders can create a sense of overwhelm and frustration, leading to an increased likelihood of missed appointments or unnecessary rescheduling. Patients may feel bombarded with information, causing them to tune out important messages or become disengaged from their healthcare providers. This, in turn, can lead to a breakdown in communication and hinder the delivery of effective care.

However, it is important to note that not all appointment reminders are created equal. Some healthcare providers have found success in implementing personalized reminders that take into account the individual patient’s preferences and needs. These tailored reminders can help alleviate the sense of overwhelm and improve patient engagement. By allowing patients to choose their preferred method of communication and frequency of reminders, healthcare providers can strike a balance between keeping patients informed and respecting their autonomy.

Moreover, the constant stream of reminders can contribute to heightened levels of stress and anxiety among patients. Instead of feeling supported and reassured, patients may develop a sense of unease, fearing that they are missing critical information or forgetting important appointments. This increased stress can have a detrimental impact on both their physical and mental well-being, further straining the patient-provider relationship and impeding the delivery of optimal healthcare.

To mitigate the negative effects of excessive appointment reminders, healthcare providers can explore alternative approaches to communication. For instance, implementing patient portals or mobile applications can provide patients with a centralized platform to access their appointment information, reducing the need for multiple reminders. Additionally, healthcare providers can invest in patient education initiatives to ensure that patients are well-informed about their upcoming appointments and understand the importance of attendance.

Furthermore, it is crucial for healthcare providers to regularly evaluate the effectiveness of their appointment reminder systems. By collecting feedback from patients, providers can identify any pain points or areas for improvement. This feedback can inform the development of more streamlined and patient-centered reminder systems, ultimately enhancing the overall patient experience.

In conclusion, while appointment reminders play a crucial role in ensuring patient attendance and engagement, excessive reminders can have a negative impact on the patient experience. By implementing personalized reminders, exploring alternative communication methods, and regularly evaluating their reminder systems, healthcare providers can strike a balance between keeping patients informed and respecting their well-being. Ultimately, by addressing the issue of excessive appointment reminders, healthcare providers can enhance the overall patient experience and improve the delivery of care.

Understanding the Overload: Why Are Patients Receiving Too Many Reminders?

Patients receiving an excess of appointment reminders is often a result of a well-intentioned but flawed system. Healthcare providers aim to ensure that their patients have all the necessary information and are reminded of their upcoming appointments. However, without a comprehensive understanding of patient preferences and needs, this system can quickly become overwhelming.

One contributing factor to the excessive reminders is the lack of coordination between different departments and systems within a healthcare facility. Patients may receive multiple reminders from different departments, leading to confusion and frustration. For example, a patient may receive a reminder from the scheduling department, the billing department, and the specific department where their appointment is scheduled. Each department may have its own reminder system in place, resulting in an overload of notifications for the patient.

Additionally, outdated scheduling systems and a lack of integration between various platforms can result in duplicate reminders being sent, compounding the issue further. For instance, if a healthcare facility has separate scheduling systems for different departments, there is a higher chance of duplicate reminders being generated. This can be especially problematic if the systems do not communicate with each other effectively, leading to redundant notifications for the patient.

Another factor contributing to the overload of reminders is the one-size-fits-all approach adopted by many healthcare institutions. Without considering individual patient preferences and communication preferences, providers may inundate patients with reminders through multiple channels such as phone calls, emails, and text messages. While some patients may prefer to receive reminders in certain formats, others may find them intrusive or unnecessary.

Furthermore, the lack of personalized reminders can also contribute to the overload. Healthcare providers often send generic reminders that do not take into account the specific needs and circumstances of each patient. For example, a patient with a chronic condition may require more frequent reminders compared to a patient with a one-time appointment. By not tailoring the frequency and content of reminders to individual patients, healthcare providers may inadvertently contribute to the overload of reminders.

In conclusion, the excessive number of reminders received by patients is a complex issue with multiple contributing factors. The lack of coordination between departments, outdated systems, a one-size-fits-all approach, and the absence of personalized reminders all play a role in overwhelming patients with notifications. To address this problem, healthcare institutions need to prioritize understanding patient preferences, improving coordination between departments, and adopting more personalized and targeted reminder systems.

Exploring the Potential Consequences of Excessive Appointment Reminders

The consequences of excessive appointment reminders extend beyond mere annoyance or inconvenience. They can have far-reaching implications for both patients and healthcare providers. One significant consequence is the increased likelihood of missed appointments. When bombarded with an overwhelming number of reminders, patients may become desensitized to them, leading to apathy and ultimately forgetting about the appointment altogether.

Missed appointments not only disrupt the workflow of healthcare providers but also result in a waste of valuable resources.

Time slots that could have been allocated to other patients are left unused, impacting the efficiency of the healthcare system. Moreover, missed appointments prevent patients from receiving the care they require, potentially leading to delayed diagnoses, prolonged suffering, and exacerbated health conditions.

Additionally, the overabundance of reminders can strain the patient-provider relationship. Patients may perceive excessive reminders as a lack of consideration for their individual needs and preferences. This can erode trust and confidence in the healthcare provider, leading to decreased patient satisfaction and the potential loss of patients to competing healthcare organizations.

Furthermore, excessive appointment reminders can have a negative impact on the mental well-being of patients. Constantly receiving reminders can create a sense of overwhelm and stress, especially for individuals who already struggle with anxiety or other mental health conditions. The constant bombardment of reminders may heighten their feelings of unease and make them more hesitant to engage with the healthcare system.

In addition to the psychological effects, excessive reminders can also have financial implications for patients. Some healthcare providers charge a fee for missed appointments, and if a patient forgets about an appointment due to an excessive number of reminders, they may be held responsible for the cost. This can create an additional financial burden for patients, especially those who are already facing financial constraints.

Moreover, the implementation of excessive appointment reminders can strain the resources of healthcare providers. Sending out a large number of reminders requires additional staff time and technological infrastructure. This can lead to increased costs for healthcare organizations, which may ultimately be passed on to patients through higher fees or reduced services.

Another consequence of excessive appointment reminders is the potential for privacy breaches. With each reminder sent, there is a risk of sensitive patient information being exposed or intercepted. This can compromise patient confidentiality and raise concerns about data security within the healthcare system.

Furthermore, the use of excessive reminders may contribute to the growing problem of information overload in today’s digital age. Patients are already bombarded with various forms of communication, such as emails, text messages, and social media notifications. Adding an excessive number of appointment reminders to this mix can contribute to the overall feeling of overwhelm and make it more difficult for patients to prioritize their healthcare needs.

In conclusion, the consequences of excessive appointment reminders go beyond mere annoyance. They can lead to missed appointments, disrupt the workflow of healthcare providers, strain the patient-provider relationship, negatively impact mental well-being, create financial burdens, strain resources, increase the risk of privacy breaches, and contribute to information overload. It is important for healthcare organizations to strike a balance between providing necessary reminders and overwhelming patients with excessive notifications.

Addressing Patient Preferences: Customizing Appointment Reminder Systems

In order to tackle the issue of excessive appointment reminders, it is imperative for healthcare providers to take a patient-centered approach that emphasizes customization and personalization. Understanding patient preferences and needs is key to designing reminder systems that strike the right balance between providing important information and avoiding information overload.

Implementing a system that allows patients to choose their preferred method of communication for appointment reminders can greatly enhance the patient experience. By offering options such as text messages, emails, or phone calls, providers can cater to individual preferences, ensuring that patients receive reminders in a manner that is convenient for them.

Moreover, streamlining the appointment reminder process by integrating various systems within a healthcare facility can minimize duplicate reminders, reducing the risk of overwhelming patients with redundant information. Collaborating with IT departments and updating scheduling systems are crucial steps in eliminating this source of excessive reminders.

Furthermore, open lines of communication between patients and providers play a vital role in addressing this issue. Providers should actively seek feedback from patients regarding their reminder preferences. By regularly evaluating and adjusting reminder systems based on patient input, healthcare organizations can ensure that reminders are both effective and respectful of patient needs.

In conclusion, patients inundated with too many appointment reminders face significant challenges that can adversely affect their healthcare experience. Healthcare providers need to recognize the impact of excessive reminders on patients and take proactive measures to address this issue. By understanding patient preferences, considering individual needs, and customizing appointment reminder systems, healthcare providers can enhance the patient experience, improve patient satisfaction, and foster healthier patient-provider relationships.

Why Do Mental Health Claims Get Denied? 10 Reasons

Mental health is a critical aspect of an individual’s overall health and well-being. However, it can be challenging to get the right treatment, especially when it comes to billing claims. Denials of mental health billing claims have become more common, preventing patients from getting the care they need. When billing claims are denied, it creates more than just a financial burden; it can also cause patients to lose access to treatment and compromise their recovery. In this blog post, we will look into the top 10 reasons why mental health billing claims can get denied and how they can be prevented.

1. Inaccurate or Incomplete Patient Information

One of the reasons why mental health billing claims get denied is when patient information is inaccurate or incomplete. This includes missing or incorrect personal information, such as dates of birth, contact details, and insurance information. Providers must ensure that patient information is complete and accurate to avoid billing issues.

2. Lack of Medical Necessity

Insurance companies often deny claims when they do not believe that a service or treatment is medically necessary. Providers must document the medical necessity of any service provided and ensure that it aligns with the patient’s condition and diagnosis.

3. No Referral or Pre-Authorization

Insurance companies may require a referral or pre-authorization from a primary care provider before they cover certain mental health services or treatments. Providers should ensure they have obtained the necessary documentation before rendering any services or treatments to avoid denials.

4. Incorrect Billing Codes

Billing codes determine the charges for rendered services or treatments. If the wrong codes are used, it can lead to billing claim denials or potentially delay payment. Providers must ensure they are using the correct billing codes that align with the provided services and treatments.

5. Time Limit Exceeded

Providers have a limited amount of time to submit billing claims to insurance companies. If the provider misses the filing deadline, it can cause a rejection or delay of reimbursement. Providers must send out billing claims within the permitted timeframe to avoid denials.

6. Claims Exceeded Allowed Services

Insurance companies have pre-approved limits for certain mental health services or treatments. If the provider exceeds the allowed limit, it could lead to a denial of the billing claim. Providers should ensure that they follow the pre-approved limits to avoid claim denials.

7. Billing for Inappropriate Services or Treatments

Providers must make sure the services or treatments they bill for align with the patient’s condition and diagnosis. Trying to bill for inappropriate mental health services or treatments may trigger denials by insurance companies.

8. Using the Wrong Modifier Codes

Modifier codes provide additional information about the services or treatments that the provider delivers. Providers must ensure they use the right modifier codes to avoid billing claim denials.

9. Balance Billing

Providers may sometimes want to bill the patient for the balance of an amount that insurance does not cover. This is against insurance rules and can lead to claim denials. Providers must understand the policies of an insurance company and avoid balance billing.

10. Inadequate Documentation

Providers must ensure that they fully document the services and treatments rendered. Lack of adequate documentation may signal an insurance company of fraudulent activities, leading to claim denials.

Conclusion:

Billing claims denials can be frustrating, both for providers and patients. However, understanding the reasons why mental health billing claims get denied is essential to avoid them. Providers must ensure they provide accurate billing information and adhere to insurance policies and guidelines. By doing this, providers can avoid claim denials and help patients receive the care they need. Always remember these top 10 reasons and their corresponding preventive measures to avoid billing claims denials.

Medical Billing and Coding Services

Medical billing and coding are generally used in the same sentence synonymously. While they are the backbone and fundamental to healthcare revenue cycle management, they are quite different.

The purpose of medical billing and coding is to ensure that providers, doctors, and service providers are reimbursed for their services by medical insurers, payers, and patients.

Medical billing and coding are completely separate processes. They codify patient visits into terms that facilitate the submission of claims and subsequent reimbursement. Combined together, medical billing and coding are called Revenue Cycle Management. It starts when a patient registers with a medical practice and ends when the doctor or provider receives full payment for all the services rendered to the patient.

The full revenue cycle process may take anywhere from a few days to several months depending on the patient’s insurance, the complexity of the case and services rendered, how the process is handled to manage rejections and denials, and how the patient’s financial responsibility is managed by the practice.

Efficient revenue cycle management, medical billing, and coding will help providers and staff of medical practices work efficiently to be reimbursed for all the quality of care that they provide.

Let us try to understand the differences between medical coding and billing.

What is Medical Coding?

When a patient visits the medical office, or any other healthcare facility, a patient visit, otherwise known as an encounter is created and the provider documents the details of the visit as well as the services provided. The patient record explains the problem, diagnosis, service, and procedures.

The process of coding is in two parts. The first is Diagnosis coding.

ICD-10 DIAGNOSIS CODES

Diagnosis codes are used to describe a patient’s condition. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) is used to capture diagnosis codes for billing purposes.

ICD-10-CM (clinical modification) codes are generally used to classify diagnoses in outpatient and private clinic settings, while ICD-10-PCS (procedure coding system) codes are for inpatient services at hospitals.

These ICD codes are used for identifying a patient’s condition, including the location and severity of an injury or symptom. It also indicates if the visit is related to an initial or follow-up encounter.

There are more than 70,000 unique identifiers in the ICD-10-CM code set. The World Health Organization (WHO) maintains the ICD coding system, which is used internationally in various modified formats.

CPT AND HCPCS PROCEDURE CODES

The procedure coding system is called Current Procedural Terminology (CPT) codes and the Healthcare Common Procedure Coding System (HCPCS).

The American Medical Association (AMA) is responsible for the CPT coding system. These CPT codes describe the services given to a patient during an encounter with private payers. AMA publishes CPT coding guidelines and any modifications each year to support medical coders with coding-specific procedures and services.

CPT or procedure codes are used in conjunction with ICD diagnosis codes to show what the providers did during and during encounter visits. These CPT codes have what is known as, modifiers, which describe the services provider in greater detail. They also indicate if there were multiple procedures done, the reason for those services, and where on the patient these procedures were provided.

It is very important to use proper CPT modifiers to ensure accurate reimbursement for all the services provided.

What is Medical Billing?

As opposed to medical coding, medical billing is the process of submitting claims to insurance companies, payers as well and patients for appropriate reimbursement. Medical coders will enter the codes described above. After that is done, the medical billing team initiates the process of claim submission.

Medical billing usually starts at the front desk. When a patient is registered, medical office staff collects patient demographics data as well as the patient’s insurance information. Once that is collected, the staff is supposed to check the patient’s coverage to ensure that the insurance company will pay for the services. If the patient does not have full coverage or adequate coverage, the patient is supposed to sign documents accepting financial responsibilities.

The office staff is supposed to inform patients that they would be responsible for any costs that are not paid by the insurance company such as copay, co-insurance, and deductible.

After the patient has checked out, the billing staff starts the process of using the codes entered by providers as well as patient information into whatever system or software is being used by the practice for the purpose of medical billing.

Data that is necessary to create and submit claims include among other things, the following:

  • Provider information including provider name, location or place of service, NPI number of rendering as well as supervising provider if applicable.
  • Complete patient demographics and insurance details
  • Visit date and related information, ICD and CPT codes, etc.

In a general outpatient office setting, claims are submitted in a format called CMS-1500 form. Most software systems submit the claim electronically in a format that is compliant with CMS-1500. Billers have to be fully conversant with the form and all its fields.

Once the claim has been submitted to the payer (directly or via clearinghouse), adjudication starts. It will be determined if there is an error in entering the data or not. This process is called claim scrubbing. If an error is found, the claim will be rejected. This is called the claim rejection process. The billing person is supposed to fix the error and resubmit the claim. If everything goes through without any error, the payer will further adjudicate the claim and determine the amount of allowable payment to the provider. Based on that, an Explanation Of Benefits (EOB) is provided and sent to the provider along with payment, if any.

To keep it simple for this article, the billing person then enters payment details and reconciles them with the explanation of the benefits document. The electronic version of the explanation of benefits is also called electronic remittance advice or ERA.

The payer insurance company may also deny the claim for various reasons. In that case the medical biller’ll prepare a case to dispute the denial and further submit proper documentation for re-adjudication.

The medical billing process can be quite tedious and complicated particularly if insurance payers reject and or deny claims. This is where there is a need for medical billers that are fully conversant with insurance rules which keep on changing very frequently.

A/R Management
The process of following up on pending payments is called A/R – Accounts receivables management. Payments are tracked, posted and denials are fought and worked on constantly to make sure providers are compensated.

Finally, any balance that is owed directly by the patients must also be followed up on by the billing team.

Part 3 – Practice Key Performance Indicators – CLINICAL

By Chandresh J. Shah

 

Clinical Practice Key Performance Indicators –  Part-3

Growing a practice can take a lot of work and having goals can help. That is why it is important to have KPIs (Key Performance Indicators) that can be used to determine how well practice goals are being met.

Let me share to you KPIs that will help your practice on 4 main areas:

  1. Front Desk
  2. Clinical
  3. Billing and Revenue Cycle Management
  4. Reputation Management

This week – Clinical KPI’s. These KPIs are:

  1. Patient Care Hours
  2. Number of Patient Referrals
  3. Patient Transactions
  4. Patient Confidentiality
  5. Patient Follow-up
  6. Rate of Complications
  7. Patient Adherence to Treatment plans.
  8. Communication between primary care, specialists and patients.

In the video below, I went through and explained what each Clinical KPI You can also download the guide through this link (Click Here):

You can also watch the first two KPI Videos.

1. Front Desk KPIs.

2. Billing KPIs.

Part 2 – Practice Key Performance Indicators – BILLING AND RCM

By Chandresh J. Shah

Growing a practice can take a lot of work and having goals can help. That is why it is important to have KPIs(Key Performance Indicators) that can be used to determine how well practice goals are being met.

Let me share to you KPIs that will help your practice on 4 main areas:

  1. Front Desk 
  2. Clinical
  3. Billing and Revenue Cycle Management
  4. Reputation Management

Let me begin with KPI’s for Billing and Revenue Cycle Management as they are the first point of contact and impression your practice makes with existing and new patients. These KPIs are:

14. Net Collections Rate

15. Total Operating Margin

16. Average Insurance Claim Processing time & cost

17. Average cost per patient

18. Claims Rejection rate

19. Average insurance claim processing time and cost

20. Average Treatment Charge

21. Percentage of Patients without Medical Insurance

22. Time Gap between Date of Service and Date Billed

23. Percentage of Claims Denied overall, and by Payer

24. Percentage of Claims Denied due to Front-end errors vs Coding oversights

25. Percentage of Patients with Public vs Private Insurance

26. Percentage of No-Response claims overall, by Payer

In the video below, I went through and explained what each KPI meant for the Billing and RCM. You can also download the guide through this link (Click Here):

Practice Key Performance Indicators – Front Desk

By Chandresh J. Shah

Growing a practice can take a lot of work and having goals can help. That is why it is important to have KPIs (Key Performance Indicators) that can be used to determine how well practice goals are being met.

Let me share to you KPIs that will help your practice on 4 main areas:

  1. Front Desk 
  2. Clinical
  3. Billing and Revenue Cycle Management
  4. Reputation Management

Let me begin with KPI’s for Front Desk as they are the first point of contact and impression your practice makes with existing and new patients. These KPIs are:

  1. Patient In-Office Wait Time
  2. Schedule Density
  3. Percentage of Electronic Health Records
  4. Confirmation and No-Show Rates
  5. Patient Phone Wait Times
  6. Check-In Efficiency
  7. Number of Patients Served Per Month
  8. Number of New Patients Served Per Month
  9. Number of Patient Referrals
  10. Staff Time Spent Entering Data/Charting
  11. Doctor-Care-to-Paperwork Ratio
  12. Percentage of Patients Who Found Paperwork to be Clear and Easy to Understand
  13. Patient Care Automation (i.e. paper work required)

Watch this “Top 40 KPI” video as I went through and explained what each KPI meant for the front desk. You can also download the guide through this link (Click Here):

Your practice is not just a routine business – You need Entrepreneur Employees

By Chandresh J. Shah

A medical practice may seem like a ‘routine’ business. However how many times have you said – “My practice is different from others”’? It is because every business owner and founder has a vision that you believe should set apart your practice from others. There is a reason why you are independent and don’t join a large hospital. It is this vision that must be articulated and passed on.

In a practice, we encounter different kinds of employees. Of course, we would want to have employees worth keeping. What characteristics of employees should you look out for? If your practice has employees that have these characteristics, consider yourselves lucky:

Committed
Innovative
Passionate
Smart
(They) Hustle but they are able to estimate the right amount of push you and others need.

Why are these characteristics a winning combination for a practice? It is because employees with these characteristics are Entrepreneurs.

Good Employee vs. Entrepreneurial Employee

The Good Employee

Most employees qualify as ‘good’ because they do their tasks well; tasks that fit into the overall vision of the founder/provider/owner. They hone in well on their particular function. These people are essential to making a business work well.

But these are not the kind of people suited to take over the entire operation. Many employees have a title that suggest they are senior and therefore are leader. That is not necessarily true.

For Doctors and providers running and managing their own practice hiring an entrepreneurial employees can be risky. That is because employees with characteristics listed above can be unwieldy and intimidating. They can and will exert their dynamic pace of action and thought.

The Entrepreneurial Employee

How do you identify these entrepreneurial employees?

They have tremendous energy. Not just during the first few months of hiring, but always – like an energizer battery. They not only work hard, they hustle. They impress with intensity.

Commitment to personal improvement. You may find them reading self-improvement books, taking evening or online courses, subscribing to personal improvement blogs. It is ambition that drives them but not just for pure ambition of climbing ladders, but personal improvement. This can lead to benefits that the practice will gain from.

They don’t like being micromanaged. Entrepreneurial employees should be ‘handled with care’. You – the practice leader – can encourage or inhibit entrepreneurial behavior. If you manage employees too closely (micromanage), creativity and entrepreneurial behavior will be stifled. Conversely, they will flourish. Entrepreneurs need space to think and create. Remove boundaries and perceived limits.

They share their plans and ideas proactively. Don’t consider this as someone trying to get close to you and impress you. They may have ideas about growing the practice, increasing patient satisfaction, increasing online reviews, increasing patient collections, and overall practice efficiency.

They want to get things done – not just talk about it. Entrepreneurs are doers and thinkers. Their thinking is done not just when you ask them but it is done way in advance. They want to act on those ideas. Many entrepreneurial employees get fidgety in meetings, get impatient because they want action not just talk in meetings.

They may threaten to leave if they are not thriving. This is the downside of hiring entrepreneurial employees. They want to see growth and success and be instrumental in making it happen. It is up to you to create an environment where they thrive. Share your vision and work to have them make it their own. If there is a disconnect, this employee is perhaps not a good fit.

They may not be excellent team players. Sometimes, the most entrepreneurial employees don’t work well on teams. They don’t think like other people, and may have trouble understanding or empathizing with alternate points of view. These are not bad team members, their entrepreneurship needs to be harnessed.

Working with an entrepreneurial employee

I was helping a good friend and client several years ago. His practice was struggling to grow. He had just lost a provider/partner. One of his employees did not have the ‘office manager’ title, but she acted and behaved like one. She was a hard charger and driver. She intimidated everyone, but at the same time, other employees respected her for her knowledge and tenacity. They implemented a new EHR. She learnt and mastered it to the point where she became the internal ‘guru’. Even billing staff reached out to her.

The owner provider was concerned and scared. He was contemplating letting her go because even he felt intimidated. We talked it over and established a 6 month plan. We gave her a vision for personal and practice growth, and linked them together. We established boundary conditions and left her alone without micromanaging. We met with other staff members and sought out their feedback and articulated her role.

After 6 years, she is the office manager – she’s happy and the practice has grown tremendously.

Recognize and seek out entrepreneurial employees, you will not regret it.

Let me know if I can help. Pick a time on my calendar to discuss ideas. (Give it a few seconds for calendar to load after you click)