Home Page > Eligibility > Pre-authorizations > Tips and Tricks: Getting Your Practice Paid

Tips and Tricks: Getting Your Practice Paid

In today’s changing healthcare reimbursement environment, it’s more important than ever for your practice to use top billing methods to maintain a healthy revenue cycle. You should know how to identify potential problems, benchmark data, and ask appropriate questions along the way. Hopefully the answers to the commonly asked questions below will help you get on the right track to getting your practice paid.

Question 1: Should our practice verify eligibility and benefits every time a patient comes for a visit or should we only verify for new patients?

Answer: Checking eligibility and benefits should be considered on a case-by-case basis depending on both the patient and his or her payer. For example, existing patients covered by Medicare will not need to have an eligibility check each time they come into the office and neither will patients who come regularly for maintenance procedures. It’s also a good idea to check all patients in January – or at their first visit of the year – after the open enrollment period since some of their plans may have changed.

Question 2: How many payers does the average practice have, and is it feasible to manage each payer individually?

Answer: The number of payers each practice accepts depends on the market; some practices work with one payer 80 percent time while others might work with 80 payers at a time. The important detail to be aware of is the different plans offered by each of the payers. To best maximize your staff’s efficiency, you should focus on diligently building relationships and learning about the nuances of the top five to eight payers you work with most. The smaller payers can then be put in a category together so managing them doesn’t become too overwhelming.

Question 3: How should we address authorizations received from health plans that include language about authorizing the procedure, but not necessarily payment for the procedure?

Answer: If your contract with the payer allows it, it’s often best to have patients sign a waiver that states they understand they will be responsible for payment if the procedure isn’t covered by the payer. This will require you to give the fee-for-service on the front-end, but it can help your practice increase transparency about service costs. If a patient is going to have to pay for a service, you should let them know what the timeline for payment expectations are, but also that you are willing to work with them to create a payment plan, within reason, that fits their needs.

Question 4: Where should responsibility for pre-authorizations fall within the billing department?

Answer: There are a number of staff members who could handle pre-authorizations (and other billing tasks), so you should consider which person has the best knowledge of pre-authorizations and the time available to complete the task in tandem with his or her other duties. Handling pre-authorizations in the scheduling department often works for most practices so that they can be made before the appointment is scheduled and the service is provided.

Question 5:  How many staff members does the billing department at my practice need?

Answer: The best way to determine how many staff members you should have is by claims volume, rather than the number of physicians you have or the number of patients you see each day. The industry standard for backend staffing is one billing full-time equivalent (FTE) for every 10,000 claims. You should also consider how much your practice collects on the front end because this will affect how staff should be allocated.