Billing and Collecting With Care

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PhyCon Inc. uses real time performance measures to help physicians stay accountable.

***This article was written by one of EPM’s advertising partners as a promotional supplement.***

What does an emergency physician do when he or she is confronted by a problem that doesn’t seem to have just the right answer? They invent a new approach, treatment or technique. That was the situation facing Paul Orcutt, MD, FACEP in 1986, which led to him founding PhyCon Inc., a new RCM model for ED billing and collections.

Orcutt was the director of what developed into a large, successful and regional emergency medicine group with 50 physicians and 75 mid-level practitioners in Oklahoma. Early in his billing and practice career of 33 years, Orcutt noticed — as with most groups — there are wide variations of a group’s work output as reflected by the patient documentation, number of patients seen per hour, and acuity levels that have to be appropriately accounted for in the practice. The problem was complex and multifaceted.


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The results showed there were wide variations in levels of billing in the group. If this only affected the individual physician, it would be none of the group’s concern, but each physician was incentivized with a production based RVU profit sharing contract. Also, hospital based physicians would be in the line of fire and if some of the members inappropriately under-documented they would injure the base compensation of the entire group and/or diminish the hospital’s revenue.

After much thought and trial runs, Orcutt and PhyCon president Donna Stubblefield developed and implemented a continuous documentation training plan that now has spread to help other national groups to become more profitable and compliant.

Orcutt developed the program to give EPs and their group real time performance information via daily generated documentation and performance reports. The individual physician can see how they are doing and also compare themselves to the group through a business intelligence program called PhyConPM dashboard and the PhyScore Report Card.


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PhyScore-card -- place around fourth graph

The result is not only improved performance by individuals, but a sense of group pride with respect to improved performance. When the weakest performers improve, all involved gain. Each month a PhyScore report card showing the physicians’ scores are emailed to each member with concise details of their work performance and how they compare to the group. You can access more group and individual details on the PhyCon PM dashboard through your Tablet, PC, MAC and mobile device.

For example, when the PhyCon coding staff finds a critical care time has not been documented they send the provider an email that day noting which patient was not appropriately documented and is reported in the PhyCon PM dashboard as an undercode. The dashboard tracks this information and is a part of the daily and monthly report of each physician and how they compare with the group locally and regionally. Additionally, other examples are monitored in real time as well as infractions of over-documenting a record prior to billing. The ED physician and the midlevel practitioner are thus educated on a continuous and daily basis as well as attending many on-site coding and billing seminars.

Timeliness is key. When individual physicians fail to document in a manner that accurately reflects their work it is important to give feedback in a timely manner while the physician can still recall the details of a given patient. That’s when real learning or clarification of the record occurs. This daily prepping is just a small part of our overall compliance plan that has been developed over the past 30 years, keeping PhyCon’s clients assured and accurately reimbursed.


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Not every failure to collect the appropriate amount is the problem of the doctor’s documentation. Sometimes up to 15 percent of billed claims are arbitrarily down-coded and paid at a lower rate by insurance companies and government payers. The PhyCon audit team frequently encounters critical care claims down-coded to a level IV or level III. PhyCon appeals all down-coded claims!

If these amounts are not individually reconciled in a timely manner, hundreds of thousands, and sometimes millions of dollars are lost by not performing the appropriate and costly job of appeals. Most crucially, the physician groups are not made aware of this massive loss of intrusion by the insurance carriers in part because most billing companies do not report this data because they are not willing to work with little reimbursement for them. If these amounts are not individually reported and reconciled in a timely manner, millions of dollars will slip right through those hard working hands. And finding the down coded charts is just the beginning. That’s when the personal touch — the really hard and costly work — has to occur.

The insurance companies have other ways to lower a group’s reimbursement. Most ED groups and hospitals are unaware that every physician who is credentialed with a given insurance company has many profiles, all paid at different/lower rates. Insurance billers will sometimes pick a profile that has the lowest compensation. But that collection is the hardest to get. Each underpaid bill must be individually appealed. That’s when many billing companies find that such costs are simply not cost effective for their return on the effort.

PhyCon was founded so physicians would get the reimbursement they have worked so hard to achieve.   Thus when you do negotiate with payors, the revenue management team will be at your side to give you the expertise to get everything you are entitled. It’s that personal touch. They even have an on-site employee at each location plus in-house IT and programming departments for seamless integration with your hospital systems.

Emergency physicians are innovative, that’s why it’s not surprising a billing company developed and operated by an emergency physician does things a little different. Specifically with a further down in the trenches of everyday practice problems mindset and an approach that’s more than the one-size fits all take of many billing companies.

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