Getting paid for medical care is hard.   

It is not enough for doctors and providers to understand the overall revenue potential of their planned services, they must solve the details of getting paid day-to-day.  This means no claim can be left behind.  Best performing practices collect 97% or more of allowable payments for their contracted and submitted claims.    

Reimbursement for medical services depends on complying with a complex set of rules that vary by payer.  When a claim does not get paid on the first pass, there is a cascading set of potential reasons that could be in play.  These unpaid claims fall into an accounts receivable asset for the practice.  Success in converting these unpaid claims into realized revenue is critical to the overall financial success of each provider of medical services from hospitals to mental health counselors.

Why don’t payers pay?

Beyond the obvious, payers don’t want to pay if they don’t have to, is the contractual and rules structure in place for each payer.  Payers cover the financial costs of care for their members. They contract with medical providers to provide care, and then reimburse them for these services.  These contracts form a web of promises that define their responsibility to pay for services.  It is in their interest to not pay a claim unless it fully meets the terms of their agreements with providers and patients.  There are a cascading set of reasons why they don’t pay.

Did the payer get the claim?

Was the claim sent to the correct payer?

Was It a contracted service?

Was It billed correctly?

Was the denial consistent with the payer rules?

Does the payer need more information?

Did the payer make a processing mistake?

Correct Coding and Clean Claims Is The First Defense For Unpaid Claims

The most efficient claims collection process would see every claim paid on the first pass. Best performing practices get paid on 95% or higher of submitted claims.  This means that revenue flow for the practice is fastest, and the cost of following up on unpaid claims is as low as possible. Correct coding and pre-submittal claim scrubbing eliminates failed claims.  This means the claim creation process needs to be smart and meet payments requirements when they are generated.

Deep AR Analysis

The most efficient claims collection process would see every claim paid on the first pass.

Getting to the bottom of the reason for non-payment is a detective job that has three financial consequences.  It cost money to chase payments claim-by-claim, delays initial income for the practice and delays billing and revenue from secondary payers and patients for total payment for the claim.

Experts in AR follow up are crucial in the medical payment collections process.  Professional AR collectors:

• Know the specialty and correct coding.
• Know the details of the contract for the practice and payer.
• Know the special rules of each payer.
• Make the case for persistently with supporting information for payment

The Role of Automated Rules And The AR Tracking Processes

The data used to create and process claims across multiple payers and specialties creates a performance history.  Deep analysis of this claim payment history provides a knowledge base to apply to a current claim.  This can benefit the initial scrub process and catch errors before they cause a denial.  They also provide fast analysis tools so when claims are not paid, the reasons can be quickly identified, and appropriate action taken. A combination of tools like Microsoft Power BI and proprietary analysis tools combine to turn data into insight, and insight into action.

About MDCommerce Inc.

Formed in 1996, MDCommerce is a healthcare information technology company with a talent pool with long experience across multiple specialties helping providers of care and their patients achieve gold standard reimbursement for care.  By applying advanced technology to the medical billing and collection process a connected loop process from claim scrubbing to AR follow up. Our quest for full payment is applied to millions of claims annually delivering provider revenue of hundreds of millions in collected claims.