Is your program billing for every service rendered? Many program administrators and physicians believe they are billing at 100% but often do not have any processes in place to verify the accuracy of their billing. Furthermore, billing is often viewed as a "clerical" function rather than a multi-step process that involves just about everyone working in the clinic. In establishing a thorough billing program, it is important to recognize that this is not just a "data entry" function that only clerks or someone in the billing department performs. If 100% of revenues are to be truly captured, then everyone involved with the patient encounter must understand their role and its overall importance to the billing function. Consider each role and its importance in the overall billing process:

Marketing & Sales Staff:

• Initial company profiling;
• Communicating profiles to others;
• Accurate registration information;
• Correct company and visit type/protocol selection;

Patient Care Staff:

• Verify with patient why s/he is there, e.g. for a pre-placement drug screen;
• Mark superbill or protocol spec sheet for all services rendered;
• Double check spec sheet for completion of all required services, and whether each service or supply rendered is marked on the superbill or posting record;

Physicians:

• Mark superbill or protocol spec sheet for all services he or she has rendered;
• Note visit level and all diagnoses, with sufficient clinical documentation of diagnosis and treatment rendered to support workers’ compensation requirements;

Posting/Billers/Site Supervisors:

• Capture and enter correctly all services from charge sheets (superbill/posting record);
• Clarify diagnosis, notes or any other documentation on work injuries that may be vague or missing;
• Share EOB (Explanation of Benefits) information with physicians and staff for accuracy or changes in workers’ compensation billing/reimbursement methods;
• Auditing and bill review: monitoring data entry and physician and staff performance for errors, omissions or missed opportunities, particularly in workers’ compensation.

Billing is really a 360º view of your clinic—everyone impacts the process, its accuracy and ultimately the revenue generation for your clinic. When staff claim they can not improve revenues, they couldn’t be more wrong! By simply verifying their work and those of co-workers, they can insure that inadvertent omissions due to human error do not occur. Clinics are most prone to mistakes on busy days, when they are running short staffed, or when new employees or physicians are introduced to the process. In addition, workers’ compensation is a game unto itself and requires special focus, particularly from physicians and the billing department. Consequently, training and auditing become key tools for insuring that your program is in fact billing as close to 100% accuracy as possible.

To improve and tighten your billing process and verify that you are capturing and billing all of your charges requires a multi-step program. The hallmarks of a good program are:

Orientation: Work with your current staff and billing department to develop a thorough billing orientation program that emphasizes the critical processes of each position. Positions that are responsible for data entry (registrars, posters and/or billers) will require more specialized, in-depth training. For these individuals, you should develop a training program that delves not only into the basics of your computer system and the basics of registration and posting, but also a thorough review of workers’ compensation billing and reimbursement.

It is also important to design something that meets the unique needs of your physicians. Medical school does not train physicians in the technical art of coding and charting to accurately capture charges, particularly in workers’ compensation. All new physicians should go through some kind of education program on CPT coding and documentation as well as workers’ compensation regulations that impact reimbursement. Physicians should take an active role in working with the billing department, or whomever is most knowledgeable about workers’ compensation reimbursement for your system, to design an orientation and training manual for your physicians. Full-time physicians should also be responsible for orienting newer physicians and initially supervising their work to verify that all charges and services rendered have been accurately captured.

Training: Once everyone is initially trained, take the time to periodically reinforce key elements of the billing process. This also presents an opportunity to discuss any changes in workers’ compensation and to engage staff in a discussion of their most common questions, problems or frustrations. Educational sessions are also an opportunity to review the findings of audits and "error" reports to reinforce correct techniques that minimize mistakes, better instruct all physicians and staff on the nuances or changes in workers’ comp and ultimately improve the capturing of gross revenues.

Monitoring & Audits: By tracking common mistakes, which are also lost revenue opportunities, you can accomplish several goals: process improvement benchmarking for JCAHO; operational improvements which should also reduce billing errors that contribute to re-work and, often, dissatisfied customers; and an improvement in gross revenues and the bottom line. Monitoring and auditing the billing process can be as formal or informal as you choose. Ideally, monitoring and auditing should be performed at the clinic level (during orientation periods of all new staff and a weekly chart review of all workers’ comp cases by site supervisors) and within the billing department, after posting and receipt of EOBs (Explanation of Benefit forms).

If you have not audited your billing processes before and are just getting started in operational enhancements for your program, you will probably want to take a more formal, detailed approach to your review process. This is the only way you will be able to estimate how accurate (or inaccurate) your current processes are and how many resources you will need to improve existing processes. Initial error rates between 3-10% (or more) are not uncommon. These errors typically are missed charges: either the patient care or physician staff failed to mark a superbill when the service or supply was provided; the service was never posted; or under state law, alternative visit levels or charges should have been used.

Feedback: While always important, feedback is perhaps most critical in workers’ compensation billing. While the CPT Coding Book has a wealth of information that your staff must understand, there are always aspects to individual state’s workers’ compensation rules that are unwritten and subject to change. Workers’ compensation billing becomes something of trial and error as to what is reimbursable—and that information, as it is gleaned from EOBs, must be communicated in meaningful timeframes by the billing department to operations.

Understand a key issue: the primary goal of an insurance payer is to pay as little as possible and hold onto money for as long as possible. Insurers are continually looking for new approaches to help them meet that end. A constant cycle of feedback and adjustment in procedures is critical to maintaining the best possible reimbursement for services.

It is also important to recognize that billing for elective services is much more straightforward than billing for workers’ compensation. Your processes and audits for elective services will focus on:

• Was the correct company selected?
• Was the correct protocol or visit type for that company selected?
• Were all of the requested services delivered and up to the customers’ expectations?
• Were all of the requested services posted/billed correctly?

For workers’ compensation, your processes and audits will focus on the above in addition to:

• Was the correct visit level chosen?
• Is the correct diagnosis and coding noted on the superbill and is it supported by thorough documentation?
• Were the services rendered consistent with the diagnosis and chart notes?
• Were all possible revenues captured – especially dispensed supplies and medications?
• Were all services and supplies rendered posted/billed correctly?
• After the EOBs are received, what modifications were required and could they have been avoided through better education of staff and physicians?

Tightening the many links in the billing process will take time, but the return on your investment of time and a few resources will result in a direct increase to your bottom line. In many programs that have not examined their billing process in great detail, missed revenue, either through ignorance about the nuances of workers’ compensation billing or plain human error (failure to enter charges), can easily result in the loss of 3-10% of existing revenues. For a program billing one million dollars per year, that can represent $30,000-$100,000 that has not been captured.

While this is not the panacea for all of your program’s financial woes, a close examination of your billing process across the department will, in all probability, identify numerous opportunities for improvement that can result in the enhancement of your net revenues and bottom line. Provide orientation and training for staff and physicians on correct billing procedures and establish the expectation that everyone will check his or her own work as well as the previous work of others. The result will be that many potential errors or omissions are caught "real" time and corrected at the point of service before the posting and billing process is complete. Perhaps the greatest satisfaction out of this endeavor is the verification that your program is, in fact, capturing 100% of the revenue for all services rendered.