Some of the sources of revenue to analyze are fairly obvious. First, you should be reviewing a trend analysis on all major payers and/or financial classes. For most ED groups, these generally include Medicare, Medicaid, Blue Cross/Blue Shield, Workman’s Comp, and prominent commercial insurance plans. If you don’t receive this information today, you must request this immediately from your billing vendor as this is critical. I would also recommend that you review the payments from all of your contracted managed care plans. We all know that insurance plans have a long history of paying less than contracted as evidenced by the large number of class action lawsuits lost in the last decade. Beyond verifying the correct payment for evaluation and management codes (99281-99291), make certain these plans as well as prominent insurance plans are not bundling reimbursable charges into the level of service. Examples of codes commonly bundled inappropriately include EKG interpretations, X-ray interpretations and pulse ox. Insurance companies can save millions by bundling or paying slightly less than contracted rates. In my view, they must be saving far more than they are losing in the lawsuits because they continue to repeat the actions previously deemed inappropriate by the courts.
The real world
Here’s an example of how this has played out in real life. One of our physician group clients opted not to contract with a major insurance plan as they were not offered reimbursement deemed appropriate by their management team. The insurance plan then went and contracted with a small “network” which gave them access to the network rates. The group had originally contracted with the small “network” due to pressure from the hospital. The small network which had represented less than 1% of their volume quickly became 6% of their volume due to this large insurance plan. Had the change not been spotted during the first sixty days, the group could have lost hundreds of thousands of dollars annually because the small “network” reimbursed 125% of Medicare rather than the 80% of billed charges previously collected from the large insurance company patients. Fortunately for the group, they had worked with their billing team and other advisors to place contractual language that protected them from this type of activity.
Bryan Vinyard is the president of comprehensive medical billing solutions. www.compmedbill.com