Practice Management Software and Workflow. What comes first?

Modify the EHR to fit your current workflow or adjust workflow according to the EHR system. What should you do?

Wrong question. It is like putting a cart before the horse.

In the past few weeks, I have talked a lot about practice revenue and revenue cycle management. Let me focus on that as I try to explain what I mean.

Examine some possible problems or ‘current state of affairs’.

Example 1

Overall collections are not bad, but there are two issues that can be improved:

o   Patient collections down

o   Few Denials too many!

The billing department (in-house or outsourced) is doing a good job. The over-90-day accounts receivables is within industry norms, they work very diligently to pursue all claims and every last dollar. They are doing everything they can, within their power.

The problem is, there are things that can be done better upfront – before the patient comes in, before the claims go through. How?

-          Getting pre-cert done for procedures before-hand.

-          Getting eligibility for special type of visits before patients walk in so that you are not caught with pants down.

-          Full knowledge of Patient co-pays, out of pockets and balance remaining on deductibles, before patient comes in for a visit.


Examine your practice workflow with respect to these specific problems.

-          How/Who can check eligibility and other insurance details before patient visits?

-          How/Who can check insurance details, outstanding patient balances, pre-certs, authorizations?

-          Once checked, what should be done to take care of and/or avoid downstream problems?

Example 2

Your practice receives a paper EOB and check for 10 claims. You receive this check on 1st of the month. Someone enters payment into your billing software and deposits the check into the bank. The person in charge of payment posting is not able to post the payment until after 2 weeks, say 15th of the month, for whatever reason.


The Billing Manager runs the ‘payment’ report where there is a discrepancy.

She wants the report to reflect Payment Posted date to match the date when the check was received.

Read the above sentence again. Do you see anything wrong with this?

First of all, every activity in any system should reflect the date when that activity is performed. If the software reflects the date of payment posting on a claim as May 1 instead of May 15, that is exactly what it is.

So, why does the billing manager want the payment posted date as the date on check? If the reason is to be able to accurately reconcile the claims payment date, then the payment posting process needs re-examination, not the technology or software!

Therefore, the answer is to link workflow and processes to Problems and Solutions rather than technology.


Practices are too close to the problem to realize that the process is broken, or can be improved, because it is based on assumptions and conditions that were established a while ago. Environments – business and technology – change, which requires adaptability to change processes.

Successfully solving problems requires partnership and information sharing. It is a result of two or more people sharing the workload and committing to same outcome.

If you see your vendor as a vendor that is simply making and peddling software, you’re on your own. If you see your vendor as a partner allow them to help you, they have a lot of experience and you don’t have to pay ‘consulting’ fees to more expensive health IT consultants.

A vendor that says yes to everything you want should be approached with caution. Is the vendor challenging you to think of your current state and encouraging you to visualize a better future state? If yes, proceed.

Practice Financial Analysis - Part 8 - Possible Embezzlement

This week is a continuation of the high-level financial analysis of your practice.

Part of this analysis involves looking into your collections and related gross collection percentages. However, collections do not always meet expectations and there are a few possible reasons you should look for:

1. Shift in your payer mix (click here for last week's article)

2. Decline in reimbursement rates

3. Poor follow-up on unpaid insurance receivables (Insurance A/R)

4. Poor front desk collections

5. Poor claim filings

6. Not sending out patient statements

7. Poor patient receivables management (Patient A/R)

8. Possible embezzlement


This week I will be focusing on the 8th and last reason : Possible Embezzlement

Declining revenue and rate of collection is certainly possible because of employee embezzlement. Although this is not common, it is not entirely uncommon either.

Is there a possibility of embezzlement in my practice?

If your revenue is declining despite having  a good payer mix, while your production has either stayed the same or increased from the previous year and nothing else has changed in the practice, you can look into the possibility of embezzlement. However, it will not be wise to jump to an unfounded conclusion. Looking at this possibility will require that you look carefully  into a couple of things and before looking into  employee embezzlement.

What reports do I need to review to evaluate objectively?

To help evaluate this, you should have comprehensive reports that lists month over month the practices’:

  •   Production

  •   Collections

  •   Gross collections percentage

  •   Adjustments

  •   Adjustments percentage

  •   Net collections percentage

Once you have these reports, you should then compare amounts written off as contractual’s against your payer mix. Evaluate if this appears reasonable. If your contractual adjustments appear larger than they should be, ask yourself if embezzlement is possible.

Embezzlement through contractual adjustment is a common way for money to be stolen in the medical office. The simplest way to prevent this situation is to make sure the staff who posts payments into the billing system never touches checks and currency. These two must be separate people with separate responsibilities.

Practice Financial Analysis - Part 7 - Poor patient receivables management (Patient A/R)

This week is a continuation of the high-level financial analysis of your practice.

Part of this analysis involves looking into your collections and related gross collection percentages. However, collections do not always meet expectations and there are a few possible reasons you should look for:

1. Shift in your payer mix (click here for last week's article)

2. Decline in reimbursement rates

3. Poor follow-up on unpaid insurance receivables (Insurance A/R)

4. Poor front desk collections

5. Poor claim filings

6. Not sending out patient statements

7. Poor patient receivables management (Patient A/R)

8. Possible embezzlement


This week I will be focusing on the 7th reason : Poor Patient Receivables Management (Patient A/R)

A large share of your reimbursement dollars now comes from the patient.

As we saw in last week’s article, as patient outstanding balances are on the rise, this  requires the practice to focus on front desk collection and , sending patient statements consistently among other things.

This week we will focus on various tactics to reverse poor patient receivables management.

Many practices resort to collections agency when patient balances grow out of control. This is not always the best approach. Turning over patient account collections is usually recommended as a last resort.

Knowledge is Power

The best approach to address patient account collections is to get patients to pay their bills in full, upfront whenever possible. This is where the front desk and phone staff play critical roles.

However it is important to note that the staff must be trained to be knowledgeable about patient balances. To engage in a financial discussion, they must know what amount is due at the time of the visit and also if there are any outstanding balances. This is essential as staff can be in a precarious position because they have to maintain good relations with patients while asking patient for payment and their level of knowledge can affect this. This must be ingrained in the culture of the staff. Each practice must have written policies not just for the patients but for the practice staff to follow.

A staff who tries to get patient payment on time of visit but is not be able to adequately answer a patient ‘s queries about their bill can affect how patient perceives the charges on their bill. On the other hand, if a staff is knowledgeable, he will be confident, firm and assertive yet still being able to keep a smile. There is a higher chance the patient will want to pay as they recognize that and more opt to meet financial obligations.

Decide on timeline for patient collections.

After sending patient statements as described in the last article, if a patient fails to pay the balance within a reasonable amount of time, you should begin mailing firm letters with an increasing sense of urgency. This is because according to various surveys there is a less than 30% chance of collecting money from a patient if that balance reaches 90 days.

If possible, you should have an in-house person or an outsourced person make physical phone calls to patients. Again, only using an external collections agency as a last resort.

After all possible methods have been tried, the practice must decide whether to write off small balances or turnover in account to a collections agency. Many things go into the decision-making process such as positive and negative impact of an unhappy patient and the time and effort and mental stress involved in pursuing collections. In any case, a written guideline should be in place.

Below is a summarized guideline every practice can implement:

  1.   Use technology to perform automated eligibility check as a part of scheduling and check-in process.

  2. Ensure pre-certification, authorizations, and referrals are in place before the visit.

  3. Collect co-pay, outstanding balances, deductibles etc. at the time of service.

  4. Make it easy for patients to pay by sending he- statements, enabling online bill payment, accepting credit cards, setting up payment plans etc.

  5. Train and retrain staff to make sure that everyone knows the patient billing process and is capable of having a financial conversation with patients.

As a last thought to this subject, in spite of everything, keep a smiling face, understanding that paying bills is not easy for anyone. Don’t make it personal. Help the patient understand that you are personally not asking them to pay, it is a combination of the insurance company and the doctors for the excellent quality of care that is provided.

Practice Financial Analysis - Part 6 - Not sending out Patient Statements

This week is a continuation of the high-level financial analysis of your practice.

Part of this analysis involves looking into your collections and related gross collection percentages. However, collections do not always meet expectations and there are a few possible reasons you should look for:

1. Shift in your payer mix (click here for last week's article)

2. Decline in reimbursement rates

3. Poor follow-up on unpaid insurance receivables (Insurance A/R)

4. Poor front desk collections

5. Poor claim filings

6. Not sending out patient statements

7. Poor patient receivables management (Patient A/R)

8. Possible embezzlement


This week I will be focusing on the 6th reason : Not sending out patient statements.

It is becoming clear that the largest bucket of aging and outstanding balances is patient balances. Cost of treatment is increasingly shifting to patients. Co-pays and deductibles are rising. Every practice must manage patient payments.  However, many practices fail to send out patient statements on a timely basis or are not even sending them out at all.

Patients who do not receive statements every month cannot pay their accounts. If statements are not sent, regularly at the same time each month (either through  paper statements or electronic statements), cash flow will become a problem. Let me explain what I mean below:

On Patient Outstanding Balances

Most practices seem to concentrate their follow-up on unpaid insurance accounts since they tend to represent a larger portion of the total receivable and also these unpaid accounts usually have larger balances. However, patient receivables must not be overlooked.

A quick glance through the aging report will show that older accounts will be patient outstanding balances. You must have a follow-up policy for those accounts. It is not always practical to follow-up with patients on the phone, which is why patient statements are important.

On Front Desk Collection

Another important element is to ensure that practices have appropriate front desk collection procedures when patients are scheduled and when patients come in for their appointments. Most technology solutions of practice management today allow the front desk to quickly view patient outstanding balances.

These problems are minimized if patients are received at the time of the office visit and if overdue balances are discussed with patients at the time of their office visits.

Consistency is the key

Accounts receivables can be minimized by mailing patient account statements each month. A consistent process must be established within the practice and necessary emphasis on this important part of the collection process should be given.

Patient statements  are available and each practice  should take advantage of sending electronic statements that can be emailed to patients . These electronic statements  are becoming more accessible and easy to use as it  allows  patients to  pay online so take advantage of it.

Practice staff must also be trained to answer patient questions related to their statements when they call. This means they must know the status of claims, insurance payments, patient balances, and more importantly learn proper techniques of dealing with patients to be able to collect on the phone either as payment in full or even partial payments.

Get help if needed

If the practice is very busy, you should also consider a dedicated virtual staff that can help out. It has been proven that emphasis on patient statements and balances not only helps the bottom line but also results in happier patients.

Practice Financial Analysis - Part 5 - Lower collections because of poor claim filings

This week is a continuation of the high-level financial analysis of your practice.

Part of this analysis involves looking into your collections and related gross collection percentages. However, collections do not always meet expectations and there are a few possible reasons you should look for:

1. Shift in your payer mix (click here for last week's article)

2. Decline in reimbursement rates

3. Poor follow-up on unpaid insurance receivables (Insurance A/R)

4. Poor front desk collections

5. Poor claim filings

6. Not sending out patient statements

7. Poor patient receivables management (Patient A/R)

8. Possible embezzlement


This week I will be focusing on the fifth reason : Poor Claim Filings.

It is extremely important to file clean claims, and this is a no-brainer and no surprises for anyone. Yet lower collection problems keep on pointing to initial claim filings not being very clean.

It is no surprise that rules surrounding medical necessity guidelines for various payers keep on changing. Medical practices must make adjustments to comply with the change. Because of these adjustments, billing staff must constantly stay on top of new guidelines. Business as usual will not work.

Proactive scanning of changes to the guidelines is most important. In spite of that, something can be overlooked and slipped. In those instances, following up on rejections can surface such changes to the guidelines which must be noted so that future errors can be avoided.

Below are top reasons to watch for to avoid rejections and denials of claim filings:

1.       Patient details.  This is one of the most fundamental things to keep in mind while filing a claim yet it continues to be 1 of the most common mistakes.

a.       Patient name spelled incorrectly

b.       Patient’s data birth on the claim does not match the data birth in the health insurance plan database

c.       Patient subscriber number is wrong

d.       Patient subscriber group number is wrong

2.       Checking for coverage eligibility of patient’s insurance. This must be done in 2 steps.

a.       The first and basic step is to make sure that the patient’s insurance coverage is active.

b.       The second is a more detailed check of determining if the specific services are powered or not.

3.       Prior authorization and precertification. Practices that provide services and procedures that are considered non-emergency may require prior authorization. Cases of this happening are more frequent than ever before. If services are provided without checking for prior authorization, your claims will be denied and it will be very difficult to get paid for them. Theoretically retro authorization is possible within a certain time period, but it is never recommended unless it is an absolute emergency and you have to provide the service without waiting to acquire prior authorization.

4.       Noncovered services. Many plans these days are basic, also known as bronze plans which exclude certain types of services. It is important to check this with the insurance before providing such services. If they are not covered, you must make sure that you inform the patient that they will be responsible for all charges. In these instances, the practice should attempt to collect and charge prior to providing the services. At the very least you should inform the patient prior to billing them.

5.       CPT or HCPCS codes.  Missing these code can will affect claims. It is up to the billing person to stay on top of these CPT or HCPCS codes changes.

6.       Timely filing. Billers must be aware of filing deadlines of each insurance carrier. In many instances, practices and providers insist that claims should only be sent after a note is signed. This practice is fine, except that it can delay submission of claims. It is my suggestion that providers should at the very minimum finalize the super bill and select the codes in order for the claim to be submitted in a timely manner. In no case, it should not be delayed more than a week from the date of service.

7.       Referral. Some services and procedures, require that a patient obtains referrals from their family physician prior to services being provided. These referrals must be on file prior to the services rendered. Obtaining a referral after the service can cause denials. It is very difficult to fight these.

Awareness and understanding of these reasons will help limit the rejections and denials to a minimum and decrease lower reimbursements due to common errors. Everyone in the practice can contribute to this- from the provider to the billing person to the front desk staff, as each can contribute to address lower collections because of poor filing.

Practice Financial Analysis - Part 4 - Front Desk Collections

Front Desk Collections

As you know, I have been focusing on a high-level financial analysis of your practice.

Part of this analysis involves looking into your collections and related gross collection percentages. However, collections do not always meet expectations and there are a few possible reasons you should look for:

1. Shift in your payer mix (click here for last week's article)

2. Decline in reimbursement rates

3. Poor follow-up on unpaid insurance receivables (Insurance A/R)

4. Poor front desk collections

5. Poor claim filings

6. Not sending out patient statements

7. Poor patient receivables management (Patient A/R)

8. Possible embezzlement


This week I will be focusing on the forth reason : Poor front desk collections.

For certain medical practices, a payment at the time of service policy should be in place. If patients do not make payments at the time of their office visit, insurance has to be filed for these services and consequently, the office must wait for its payment.

As a result, collections will fluctuate and the related gross collection percentages will not be as good as they could have been if these payments were secured at the time of the visit.

In explanation of benefits (EOB) review is very important. Staff members must be educated on explanation of benefits. Local collection percentages can be a direct result of not filing clean claims.

Patient Centered front desk collections

Customer service, or Patient service in Medical Practices is gathering more prominence. This focus creates confusion and a sense of confusion among practice owners and providers.

Does Patient Centered service mean not focusing on patient collections? Will patients be unhappy with you? Will you lose patients if you ask for outstanding balance?

Data has shown the exact opposite. Engaging patients in meaningful financial conversation actually creates a positive image of your practice and it's patient service.

I know you work very hard to take care of your patients and in fact, coach your staff to do the same. Somehow, conversation related to money is left out and avoided at all costs. Everyone feels it inappropriate to talk about money when a patient is in pain. Ironically, if you don't engage in a comprehensive conversation with patient including financial terms portrays the wrong image about your practice. Practices that engage in a holistic approach of 360 conversation including money shows that you actually care about the overall well-being of a patient.

Consider this all too common scenario:

You fail to collect copay and/or outstanding balances at front desk.

Patient receives a bill which is generally delayed because you wait for the insurance to pay their part first. By this time, patient has forgotten about the visit.

When they get the bill after a month or two, they are surprised for two reasons. One, they did not think they owed anything and second, the staff did not mention that they would get a bill after some time - or better, provide some kind of estimate.

This means the patient did not 'budget' for this and spent money elsewhere.

This leads to frustration - they may call their health plan which generally does not help. This leads to frustration. They take it out on - you guessed it, your practice - the front desk person, the biller and sometimes, even the provider.

We all hate dealing with uncertainty. Spending a little time talking to patients about money goes a long way in patient satisfaction and in the process, keeping your patient aging or patient account receivables low.


In summary, you should engage in and alert patients about statements, their financial responsibility and even educate them a bit about how their insurance plan works if possible. This is one of the best service you can do for them to maintain a healthy relationship.

Practice Financial Analysis - Part 3 - Unpaid Receivables (A/R)

Unpaid insurance receivables (A/R): What causes them, how to address them and what following up can do

As you know, I have been focusing on a high-level financial analysis of your practice.

Part of this analysis involves looking into your collections and related gross collection percentages. However, collections do not always meet expectations and there are a few possible reasons you should look for:

1. Shift in your payer mix (click here for last week's article)

2. Decline in reimbursement rates

3. Poor follow-up on unpaid insurance receivables (Insurance A/R)

4. Poor front desk collections

5. Poor claim filings

6. Not sending out patient statements

7. Poor patient receivables management (Patient A/R)

8. Possible embezzlement

This week I will be focusing on the third reason : Poor follow-up on unpaid insurance receivables.

The most common problem practices face when filing claims to insurance companies are payers who may try to delay payment or an error made by the office resulting in a rejected or delayed payment. Though practices have little control on payers, rejected or delayed payments can be resolved by follow ups.

However, follow ups do not just mean “following up, for the sake of it” as follow ups should be timely. Timely follow-up is something that everyone knows should be done. Providers, Office Managers and billers all know this. Yet, a breakdown in practice workflow is extremely common and is overlooked. It is easy to blame systems and technology than internal personnel and processes. The end result of course is that it negatively affects cashflow.

It will be helpful to keep in mind that the average time for receiving payments must be 45 days from date-of-service; not date-of-filing. Submitting claims to insurance companies is the easiest part of billing. The bigger problem is securing payment. Knowing what the holdup is may be half your battle. Yet, many practices, for various reasons don’t file claims in a timely manner. Claims must be filed the same day as the date of service.

Delay in managing this process and delay in payments from insurance companies affects monthly collections. The resulting fluctuations affects cash management and therefore owners and providers may have to dip into their personal reserves.

The overall objective is always to have a consistent cash flow from month to month. The biggest enemy of any business is unpredictability.

How to work your outstanding claims and denials?

Knowing why claims are not paid is the first step. Here are some of the most common reasons why claims may be unpaid/rejected/denied.

  1. Wrong information: Get the correct information from the insured patient. People sometimes forget that Billing really starts at the Front desk. Diligence in recording the correct patient demographics and verifying the insurance for every patient at every visit is the most critical task that a practice should do.

  2. Insurance Eligibility and Insurance coordination of benefits: Know which insurance is primary and how much the secondary insurance will pay, as per coordination of benefits. Front desk must ask patients and verify the details. Billers must know this before filing a claim.

  3. Depending on your location, insurance participation and specialty, you may be required to get a referral. Failure to do so will result in non-payment. Here too, the front desk staff plays a critical role.

  4. Missing authorization number for procedures – in-office as well as services performed at a hospital. There are ways to follow-up if a claim was rejected. If there is no authorization number on file and the insurance company requires it to pay the claim, you can submit an appeal letter with medical notes. If the insurance company denies the claim for no authorization, you cannot bill the patient; you have no choice but to write off the claim as a loss, even if you followed up on time. That is why all work upfront is important.

  5. Claim was submitted to the wrong insurance company: Expedient follow up can correct this error.

  6. Incorrect ICD-10 or CPT® code: Incorrect coding usually happens because diagnosis and procedure codes change every year in October, after ICD-10, HCPCS Level II, and CPT® code books are released for the following year. Make sure your billing system is updated with latest codes.

  7. Other: There are lots of other reasons for denials, including: invalid patient name, invalid subscriber number, wrong date of birth, wrong date of service, wrong place of service code, etc.

Following up Process-Back to Basics

If a practice has in-house biller, make sure that person is dedicated and the task of follow up is the most important – which takes precedence over any other task.

It can be difficult to follow up on claims on a regular basis, if that person is dealing with many other roles. Practices make the mistake of dumping too much work on critical employees and ask them to multi-task. This can and will take a toll on payment follow-up.

Thorough and regular follow-up on unpaid claims will result in fewer losses and more revenue.

Practice financial analysis - part 2 -Decline in Reimbursement Rates

As you know, I have been focusing on a high-level financial analysis of your practice.

Part of this analysis involves looking into your collections and related gross collection percentages. However, collections do not always meet expectations and there are a few possible reasons you should look for:

1. Shift in your payer mix (click here for last week's article)

2. Decline in reimbursement rates

3. Poor follow-up on unpaid insurance receivables (Insurance A/R)

4. Poor front desk collections

5. Poor claim filings

6. Not sending out patient statements

7. Poor patient receivables management (Patient A/R)

8. Possible embezzlement


This week I will be focusing on the second reason : Decline in Reimbursement Rates.


Many insurance companies are changing the way they pay physicians. This is a very disturbing trend.

Physicians are receiving less for their services than they were before. Many commercial insurance carriers and managed care plans are adopting Medicare’s resource-based relative value scale system as a way to pay their position providers.

Then they select conversion factors that will place the new reimbursement rate structure as a percentage of the current Medicare fee schedule.

In many cases, this switch can cause up to 40% decline in surgical reimbursement rates in that service area. Some payers in some areas of the country are even paying contracted rates less than the Medicare’s rates.

As payers reduce what they pay physicians, you can expect decline in both the practices overall collections and related gross collection percentages over time. According to some reports 65% of physicians see declining reimbursement rates as the top issue negatively affecting practice profitability.

Unfortunately, many doctors who maintain independent practices are forced to change their business model. For example, reimbursement and other cost pressures have forced 26% of physicians to stop accepting Medicaid while 22% have reduced office support staff.

But it does not have to be this way.


What can / should you do about it?

There are many ways to effectively counter these reductions. While there isn’t much you can do to stop reimbursements cuts, a proactive approach will help you offset the negative effects of declining reimbursement rates.


Increase Your Patient Base

When margins decrease, increase volume. Decreased reimbursement means per claim revenue drops. To make up for this, you need to see more patients.

Finding patients to treat shouldn’t be a problem. Number of patients joining the healthcare system has been increasing.

Making use of good tools (healthcare IT systems) coupled with optimized workflow will help you take on the upcoming patient influx without having to add more staff. Find systems and tools that focus on workflow efficiency rather than fancy features.

Consider Outsourcing Medical Billing

Outsourcing billing can make up for declining reimbursement rates by bringing in higher net collections after cost. According to a report from Software Advice, outsourced billing can bring in $1,496,000 after cost for a typical three-physician practice, compared to only $1,241,800 for in-house billing.

The savings of outsourced billing come primarily from a decrease in staff costs plus the ability to bypass purchasing billing and collections software/hardware.

Reduce Claims Denials

You must battle declining reimbursement rates by reducing claims denials as much as possible. On average, denials cost practices $25 to $30 each. There are a couple routes you can choose for reducing claims denials.

Reduce rejections and denials through patient eligibility checks and code reviews. This is the speedier and more effective route to correct claims.

The other is to be meticulous when submitting manual claims. There are plenty of opportunities for your billers to make costly mistakes. It can be something simple like misspelling a patient’s name or something more complex like misusing CPT modifiers.

Maximize Your Tax Deductions

This sounds fundamental and basic. But my CPA says many Physicians don’t pay much attention to Tax-deductible expenses which are identified as almost any purchase that helps with operating a business.

Maximizing deductions can be a balancing act. For example, offering disproportionate benefits to your employees may reduce taxes, but may also be outweighed by the extra costs of benefits. Striking the right balance can mean an increase in revenue for your practice.

In summary

Being proactive about overcoming declining reimbursements is essential for the success of your practice. Remember, inflation didn’t suddenly go down along with reimbursement rates. The problem will only get worse if not confronted right away.

Practice Financial Analysis - Part 1 - Shift in Payer Mix

In the next few blogs, I will be focusing on a high-level financial analysis of your practice.

Part of this analysis involves looking into your collections and related gross collection percentages. However, collections do not always meet expectations and there are a few possible reasons you should look for:

1. Shift in your payer mix

2. Decline in reimbursement rates

3. Poor follow-up on unpaid insurance receivables (Insurance A/R)

4. Poor front desk collections

5. Poor claim filings

6. Not sending out patient statements

7. Poor patient receivables management (Patient A/R)

8. Possible embezzlement

This week I will be focusing on the first of the possible reasons.

Shift in your payer mix

Health plan penetration can change suddenly, depending on your geographical location and service area. The current state of healthcare in our country along with many unknown variables means health plans can change from commercial insurance to managed care. Within a short period of time of less than a year, your mix of 20% managed care penetration can change to 70% as an example.

Managed care plans usually pay less because the contracted fee tends to be lower than your offices normal fee schedule. Therefore, if managed care percentage of your payer mix arises your gross collection percentage should decline accordingly.

What can happen if you fail to analyze the shift

Many offices do not analyze their financials and therefore fail to identify such a shift in payer mix until it is too late to do anything about it. Not only that, people in your geographical location can change health plans more frequently than ever before which can have a direct financial impact on your practice.

Take action- analyze

If you suspect a shift in payer mix, the first thing you should do is to get a detailed breakdown of the current payer mix. Compare that with last year. Determine what percentage of the revenue is being derived from managed care, commercial insurance, self-paying patients, Medicare, Medicaid, and other insurance programs.

Once you have all this information, find out and determine how you can shift your mix of patients to the type of patients for whom reimbursement is the highest.

How do you do this? You can come up with marketing strategies to target specific payer class. Of course, if your entire geographical area has moved towards managed care you probably don’t have much leeway. In this case you may be stuck with a reduced managed care reimbursement because there may not be other alternatives.

In any case, an analysis of payer mix will certainly let you know if that is the reason for your lower collections, and if there is anything you can possibly do about it.

Where is the Healthcare Change?


With all the news circling around healthcare these days we are likely to be depressed or frightened. No matter what your party and political affiliation is, there does not seem to be a consensus on how to crack the nut. It almost seems like everyone is a crook out to make a quick buck. Is free-market economy and capitalism doomed?

Personally, I have always been a champion of small companies. While companies consolidate all around us and large megalomaniac companies seem to run everything, it is the small companies that are the growth engine of our country. That is where people are doing all the work and where people are making decisions.

Healthcare and medical practices are no different.

I’m very optimistic about the capacity of providers to make money making us healthy and solving our problems. Large groups and hospitals seem to get into trouble all the time especially when they start behaving like an unelected ruling class.

I see new ideas and new stuff that is getting created by young people and in garages of homes every day. I may be wrong, and I hope not, but I feel that independent small medical practices are not only here to stay, they will thrive.

What do you think?

Everyone Needs a Coach - Even Doctors!

Ted talks have become a phenomenon.I'm sure you all have heard at least one good Ted talk. One of my favorite authors and thinkers in the healthcare space is Dr. Atul Gawande. Many of you may have read one of his books on the checklist manifesto.

He gave a Ted talk on 'Want to get great at something? Get a coach'

(Watch the video here)

As we know, Dr. Gawande has really been focusing on how to make things work better especially in the healthcare arena. In this talk, he says it is not just how good you are now, it is how good you are going to be or how good you can be that really matters.

He was talking about being a great physician, but I will take it further - physicians need a coach even for their other role as a business owner.

Who needs a coach?

Here is what he said, "You are never done, everybody needs a coach. Everyone. The greatest in the world needs a coach." This view comes from the world of sports.

I am transcribing some of the things that he said here.

“So I tried to think about this as a surgeon. Pay someone to come into my operating room, observe me and critique me. That seems absurd. Expertise means not needing to be coached.

Turns out there are numerous problems in making it on your own. You don't recognize the issues that are standing in your way or if you do, you don't necessarily know how to fix them. And the result is that somewhere along the way, you stop improving. And I thought about that, and I realized that was exactly what had happened to me as a surgeon.

I'd entered practice in 2003, and for the first several years, it was just this steady, upward improvement in my learning curve. I watched my complication rates drop from one year to the next. And after about five years, they leveled out. And a few more years after that, I realized I wasn't getting any better anymore. And I thought: "Is this as good as I'm going to get?"

So I thought a little more and I said ... "OK, I'll try a coach." So I asked a former professor of mine who had retired, his name is Bob Osteen, and he agreed to come to my operating room and observe me.The case -- I remember that first case. It went beautifully. I didn't think there would be anything much he'd have to say when we were done. Instead, he had a whole page dense with notes.

"Just small things," he said.

But it's the small things that matter. "Did you notice that the light had swung out of the wound during the case? You spent about half an hour just operating off the light from reflected surfaces." "Another thing I noticed," he said, "Your elbow goes up in the air every once in a while. That means you're not in full control. A surgeon's elbows should be down at their sides resting comfortably. So that means if you feel your elbow going in the air, you should get a different instrument, or just move your feet." It was a whole other level of awareness. And I had to think, you know, there was something fundamentally profound about this. He was describing what great coaches do, and what they do is they are your external eyes and ears, providing a more accurate picture of your reality. They're recognizing the fundamentals. They're breaking your actions down and then helping you build them back up again.After two months of coaching, I felt myself getting better again. And after a year, I saw my complications drop down even further. It was painful. I didn't like being observed, and at times I didn't want to have to work on things. I also felt there were periods where I would get worse before I got better. But it made me realize that the coaches were onto something profoundly important.

Billing Challenges to stay independent

Patti Van Zuuk is VP or Revenue Cycle Management. She manages over 68 practices and has a team of 107 at the time of this interview.


Biggest Challenge Small Practices Face with their Billing

CHANDRESH: When you talk to your clients, what is the biggest challenge small practices face with their in-house billing?

PATTI:  I think there are two. One, they are not acting as a business- the doctors not involved at all with regards to finances. They think they went to school for medicine and they focus on medicine and of course somebody else has their interest at heart. If provider is not checking, 9/10 times, none of this will happen.


CHANDRESH: Why are the providers not checking?

PATTI: They’ve been taught through medical school that what they should focus on is medicine and they assume that they’re going to hire this person that is going to focus on the financial side. But that’s not the case, the provider is a business owner and should be acting like a business owner. And not to say that the provider themselves have to be the checker but somebody does.


What should a good biller do?

 CHANDRESH: What does the good biller do to keep current with the codes and modifiers?

PATTI: Keeping current by signing up for all the CMS updates, using ‘super coder’ that gives you CMS updates; it’s a yearly subscription and you can also log in anytime and ask questions.

CHANDRESH: Is that a community?

PATTI: It is a community


What causes reimbursement to go down?

 CHANDRESH: The other question, some doctors always complain that reimbursements is down.

PATTI:  In some cases, reimbursements are down but not really enough to affect providers but 99% of the time it’s about coding and modifiers. Reimbursements went down as an example for balloon sinuplasty for 2018 but there’s a better code to be used, providers and billers just need to be educated to use those codes,


CHANDRESH: So as an extension of that, have you come across providers leaving their practices and joining hospitals? I talked to a few doctors and they say it’s because reimbursements are down and patient responsibility is high and patients are not paying.

PATTI: So basically, this is disfunction. I would say to any provider that tells me reimbursements are down and patient responsibility is up - I would take a look at their A/R because I would say most of what’s being lost is in the A/R. Their front office should be educated on how to collect money from patients prior to visits. I would bet that there’s a lot of money laying in A/R.


How to keep practice financially healthy

 CHANDRESH: That answer my next question, what would you advise them to keep their practice financially healthy in addition to what you just said, is there anything else?

PATTI: Proper education on what each department is responsible for.

CHANDRESH: Assuming that they have a good billing person and office manager, what should provider be asking and reviewing with their biller on a weekly basis?

PATTI: I always say from 10,00 feet, it should be charges, revenue and A/R. They should also review schedule against charges to make sure everything is being captured and charges against revenue to make sure they’re being paid completely on what they are contracted at and A/R to make sure there’s nothing laying in there.


How important are rejection rate and denial rate?

 CHANDRESH: How important are the rejection rate and the denial rate?

PATTI: Denials not so much. Denials are insurance companies asking for information. Rejections are very important, generally they are about patient demographics, whether it is their insurance or actual demographic and that needs to be corrected right away.


How important are front desk people in a practice?

 CHANDRESH: When it comes to billing and collections, what role does front desk play and how important is it?

PATTI: They’re the most important person in the medical office. They can make or break a practice, they are more important than the billers because if the front desk does what they are supposed to be doing, the biller really doesn’t have to do that much at all. The front desk collects correct information, make sure the patient is eligible, all the biller has to do is create the claim and off it goes.


What information should front desk collect?

CHANDRESH: What information should front desk collect?

PATTI: They should collect demographic information, insurance information, check eligibility to make sure that patient is eligible and patient responsibility.

Chandresh: I’m assuming that we should check and verify every visit.

Patti: Yes, insurance can change every 30 days

Patient Engagement - Best Practices - Interview

Ravi Kalidindi is the CEO of Simple Interact Inc. that provides Front Office Automation solution that helps healthcare providers improve profitability and efficiency by enabling them to acquire and retain more patients, while also automating repetitive tasks to efficiently handle high patient loads. They address front office concerns such as: Online Reputation, HIPAA Compliant Patient Intake Forms, Effective Marketing of Ancillary Services, and Automated Reminders.

I talked to Ravi Recently about his experiences.

CHANDRESH: How did you get into this?

Ravi: I have 20 years of experience in Information Technology. I worked with several fortune 500 companies especially in custom software. I saw that there was always an element of every software that has to do with customer engagement. I decided to build a reusable Cloud Based customer engagement platform. Once I got started, I realized, a) It is better to start with SMB clients since enterprise clients take a longer time to make a decision and b) It is better to start with a specific industry rather than trying to build a single solution for all industries.

I quickly realized that healthcare is one area that is behind the times in technology adoption. And since healthcare staff doesn’t have the time or inclination to learn technology, an ideal solution needs to be a simple turnkey solution. What attracted me to this industry was:

1.      Lot of activity and energy for change in healthcare

2.     There was room for innovation.

3.     There was an actual need for a simple solution for patient and staff engagement

CHANDRESH: That’s your initial research. How long have you been doing this?

RAVI: 5 years

CHANDRESH: Has your initial research been justified in these 5 years?

RAVI: Absolutely, we realize more and more that extreme simplification and low friction is necessary for software to successful.


Top challenges that small independent practices face and how automation can help

CHANDRESH: When you deal with practices, what are the top challenges that small independent practices face? Why is such a service better than physical, human calling patients?

RAVI: Small practices are usually understaffed, they can’t hire too many people. There are a hundred different things that the staff must do and its easy for them to forget stuff. There’s no need to waste valuable staff time on repetitive tasks. It makes a lot of sense to automate those things. Use that saved time for high touch patient engagement where they take time to smile, talk to patient and improve patient experience.


Patient Responsiveness to Automations

CHANDRESH: Practices certainly cannot afford a lot of staff. In these years, what have you learned? Are patients responding to such messages?

RAVI: Absolutely. The numbers prove themselves. We see very high participation rates

  • Eg. 30% participation rate on our surveys.

  • We see a lot of patients giving positive reviews,

  • Over 80% patients filling forms.

Many practices expect from experience that patients don’t want to use technology, and we always prove them wrong. One example is that despite lot of cajoling from staff, very few patients use their patient portal, so there is an expectation that a new solution will also not be very effective. We have proved that we can get over 80% of patients to fill online forms ahead of time. In other words, adoption rates are very high when you build software in a thoughtful manner.

Pew research says 80% of US citizens have a smart phone.

Every smart phone has 3 things, it has email, it has text and it has a browser. So rather than forcing people to download apps and perform complicated steps, if you just use those 3 tools, you can get very high participation rates. In addition, making things simple, and very visual. Its very significant in terms of getting very high participation rate.


Elements of Patient Engagement

CHANDRESH: So, what you mention about the success, you pointed out 3 things, patients filling out forms, patients doing reviews, appointment reminders and things like that, so what are the, in summary, what are the different services that you provide?

RAVI: Our main goal is to bring more patients through the door, that is patient acquisition and patient retention. Second part is making front office very efficient.

On the first part you want more patients through the door via local search results. Most patients happen to be local, so they need to find you in a basic local search. When they do find you on local search results, they need to see 4+ star ratings on agnostic sites such as Google, Yelp, Healthgrades, Vitals, etc not on vendor sites like which don’t carry the same weight with patients.

Once the patients come in, we want to make sure they’ll be able to quickly book an appointment; make sure that most of them show up instead of not showing up, that most of them confirm ahead of time instead of staff having to manually call, that most of them fill forms ahead of time, and instead of staff having to hand type this kind of data into the EMR and PM systems, you automate that process and push that data through.

If a practice has any ancillary services they want to market, we make it easy to identify patients who are interested in those services so the upsell rates are much better.

We automate the process of collecting self assessment data for outcome measurement so you capture the baseline score and improvements over time. Instead of relying on staff to remember these kinds of things, you just automate it.


High Participation rates of Patients

CHANDRESH: And that’s very important. You said the success rate of patients filling out forms ahead of time was high, what do you attribute that success to? Why are patients filling out those forms when the practices were initially skeptical? Why do you think that is happening?

RAVI: It’s a combination of a few things, one is user experience. One of our User Experience team members has a PhD in Experimental Psychology. We spend a lot of time designing a very usable, easy to understand interface. We tested it with patients, watched them go through the forms , identify where they stumble and where they get through fast and find ways to make that better.

These days you download an app, you don’t get training before you start using an app and if it doesn’t work, you don’t call support, you just delete the app. In short, you just expect things to work and be easy to use right away. When you’re dealing with vast demographics of patients, old, young, educated, uneducated, etc. you have to make sure everyone finds the solution easy to use. So that one aspect of it.

Then second aspect of it is low friction. Take Patient Portals for example, practices need it for compliance reasons. You are expecting patients to go to a portal, create a username password for something they are not going to use on a daily basis, so it doesn’t pass the ‘toothbrush test’.

If I’m not using something more than 2 times a day like Facebook, then I’m not going to bother creating a username and password. And another thing, I’m going to most likely forget that username password. That is the one reason why patient portals are not successful and you don’t get high participation rates.

So, what do you do as an alternative? When we send reminders asking patients to fill forms, we give them the specific links to the forms they’re suppose to fill, and we ask them information they already know like the first and last name, date of birth.

If it happens to require additional security for follow up, then we have second authorization step where it asks for a temporary pin that is sent to them via email or text. So those are the kinds of things you must do to make it more usable and reduce friction to make things work.

To lower friction, we take staff out of the picture because staff has 101 things to do. Putting staff in the mix is a stumbling block, it slows things down, makes it unsuccessful.


Measuring ROI

CHANDRESH: For a practice to take such a step, how do you help them measure ROI on your service?

RAVI: When the potential client contacts us, for each service, we provide ROI numbers they can expect because we have a lot of data from our existing client base. We show them what the cost is versus the Return on Investment. As an example, lets take our patient feedback and online reviews service, we can show that once you improve your online reputation, you could attract 40% - 45% or even 50% of your new patient business solely by improving your online reputation.

Let’s say you calculate the lifetime value per new patient ( ex. ENT patient) as $1200, so 40% of new patient business each month multiplied by $1200 is a significant amount of money which we help secure. And those online reviews are permanent. Even if you stop the service you don’t loose your reviews.

CHANDRESH: You’ve established some kind of base line metric or base on your experience working with other practices?

RAVI: We have quarterly reports so we’re able to show with any practice, what is a snapshot of their online reputation before we start, same thing with reminders, what is the no-show rate before we start and over time we can show how those numbers are improving. If there is a dip in anything, we provide recommendations and interpretations on how they can improve.


Patient Marketing

CHANDRESH: You mentioned patient marketing, how does that work?

RAVI: Typically, a lot of these practices have other services they would like to market. Let’s say an ENT practice offers cosmetic procedures, hearing aides etc. Typically, they may run TV ads in the waiting room, or have big posters on the wall, but its hard to know who is interested in what and being able to close that loop.

Whereas when patients are filling forms, they are a captive audience and its an ideal time to make them aware of various services, ask them qualifying questions and ask them if they are interested in learning more.

In general, doctors and staff members are not sales people, they are uncomfortable trying to sell something. Here the conversation is switched because here the patient is saying we want to know more about a specific service, and now the staff or the doctor is helping the patient in terms of the upsell. 40-70% patients self-identify themselves saying they want to know more about the service and even if you convert 5-10% of that, that’s a huge revenue add.

Billing Services failure - One simple reason

Medical Practices outsource their billing to companies that specialize in providing such services. 

During my conversations with practices as well as billing service providers, I constantly hear about certain practices not happy with the services that they get. I also hear about billing companies complaining about how certain practices do not cooperate. In the end, it is the practice that has to bear the brunt because of inefficient billing and loss of revenue.

I know for a fact that each billing company has majority of happy and satisfied clients. Why is it then that certain practices end up not being happy with the services?

Irrespective of the software platform and vendor, let us look at the billing process. The practice selects the codes in most cases after the patient encounter. This may be a manual or an EHR based process. The billing company creates claims and submits them. If the submission is successful, the billing company follows up regarding payment and does what it has to do post payments, run reports, and manage the aging or outstanding balances.

Theoretically, all of this should run smoothly. There are certain points of communication between the billing services company and the practice. For example, there may be problems with

  • patient demographics,
  • insurance details,
  • errors in coding,
  • need for further clarity on claims by the insurance companies,
  • proof of documentation, etc.

This is usually a manual process that is established between the practice and the vendor. And, also the main stress point or cause of failure. The process may involve faxing, phone calls, or secure messaging. There should be a person assigned in the practice that understands some level of billing process so that they can effectively communicate with the vendor. It is this middle person that plays a very pivotal role in the success of outsourced billing process.

This person does not have to be an accomplished biller or an officemanager. He or she must have the basic understanding of billing process so that they can communicate with the vendor and act as a middle person to make sure there are no bottlenecks and nothing falls through the cracks. This is the most important element of success or failure within outsourced billing company.

How to say NO as a Leader?

Here are some common places where you learn how to say NO.

There are times in life and dealing with your staff when you just have to say no. Perhaps it’s a suggestion about a strategy, execution of certain tactics, product and product features, marketing, human resources … and so on.

Or perhaps it’s about a feature that you have no intention of building, resources that you can’t dedicate, or promises that you know you will not keep. But this monosyllabic word is probably the hardest one to utter. It closes all doors and destroys all possibilities. And nobody likes to be the bearer of bad news, especially when these come from your most trusted and loyal employees that are looking out for the company as well as your clients.

So how do you say no?

According to a blog I read, here’s what the blogger suggests and I agree with it.

You cannot say ‘no’ to the people you love, not often. That’s the secret. And then when you do, it has to sound like a ‘yes’. Or you have to make them say ‘no.’ You have to take time and trouble.”

Employees will believe that as long as they think in the best interest of the company as well as clients, it will be done. Things are not that simple. Sometimes you cannot do what they are suggesting.

Most companies now sell products, but also provide professional services. It is important therefore to let clients know and keep on making them aware that you offer them. Equally important is to let clients know that the product(s) are standard off the self and not ‘work for hire’.

The problem is, sales! Sales folks will often say yes to anything when asked by prospective clients of the product’s ability to solve their problems.

Other departments that deal with the NO problem.


Prospects ask if you have certain features in what you are selling. Most sales people will go down the list of features and find out if they have the features that the prospect is asking for.

Sales stars, instead, solve a problem. Before even thinking about saying No, they will try to find out the reason behind the request for that feature. Ask Why – 5 times if you have to – to get to the bottom of the request so that you can help solve a problem and therefore turning a No into a Yes.

Customer Support

It is very similar to what I outlined above for sales. But here you have a slight advantage. The client is already using your products. They may be asking for a feature request but may not be able to articulate the reason behind that request. So, help them (and yourselves) solve the problem instead of focusing on features. If your company is offering professional services, you have an added advantage.

Back to Company Leaders

Dig in, dive in, engage employees, and understand the root cause and reasons. Instead of a flat NO, put yourselves in their shoes, and identify the issues that need to be solved. Perhaps you have a better solution, or workaround that fit within your boundaries and framework.

Copying from the Blog I was referring to (Click here to read that blog):

  • Things you CAN do + Stuff you SHOULD be doing: If you CAN do something and that’s the direction your customer base really believes you should be working on it, that’s a good reason to pump the gas on this one. These are under the radar issues that would crop up as you scale. It isn’t a customer problem currently, but it will be eventually.
  • Things you CAN do + Stuff customers WANT you to do: The Route to Professional Services. These aren’t things in your real road-map, but could offer as Professional Services. Take this route ONLY if you have the bandwidth and resources. Otherwise be nice, but say No.
  • Things your customers WANT + Stuff you really SHOULD be doing:  Road-maps to Nevada. Your current customers want it, and that is what your industry dictates you should be doing. Therefore grow, hire and provide the service or get ready with the best apology speech in the history of mankind.
  • Things customers WANT + you SHOULD + CAN do : The Commission’s Overlap of Possibility. This is your absolute high priority items. Never ever ever say NO here, even if it means shaving off a few dollars.


MACRA, Physician Reimbursement, and Moving beyond MIPS

Dr. Gail R. Wilensky, Ph.D has just wrote a thought provoking perspective in the New England Journal of Medicine. ("Will MACRA Improve Physician Reimbursement?" April 5, 2018)

Tracking the journey from Resource based relative value scale (RBRVS) and Sustainable growth rate formula (SGR) which was not really a value based system, to current MIPS portion of MACRA (Medicare Access and CHIP Reauthorization Act); it becomes clearly evident that it is still work in progress. 

MedPAC March 2018 Report to Congress - Monkey Wrench

While agreeing with the initial goal of MIPS, MedPAC has thrown a monkey wrench, claiming that MIPS is a burden along with the claim that it's goal will not be accomplished.

MedPAC shares Congress’ goal, expressed in MIPS, of having a value component for clinician services in
traditional Medicare that promotes high-quality care. However, the Commission believes that MIPS will not
fulfill this goal and therefore should be eliminated.
— MedPAC March 2018 Report

They are making two recommendations:

  1. Eliminate MIPS as it is today.
  2. Establish a new 'Voluntary' value program in fee-for-service.

As Dr. Wilensky points out, 'Under the MedPAC proposal, physicians would have 2% of their fee-for-service payments withheld. To get the withheld money back, physicians would have to join an A-APM or be part of a (real or virtual) group that is evaluated on population-level performance measures such as mortality and readmission rates, potentially preventable admissions, and patient experience. MedPAC also proposes that the measures be based on claims, which would mean that the burden would be on CMS rather than clinicians to provide the relevant data. Clinicians who do not participate would lose the 2% that was withheld.'

Even if we agree with MedPAC's assessment that MIPS has flaws, I'm not sure if anyone has the answer. MedPAC has an alternative proposal, but dumping MIPS altogether is probably not wise, until CMS tests and tries the MedPAC proposal. Dr. Wilensky proposes that CMS should test it under its Innovation Center (CMMI).

In either case, we are certainly making progress. This is such a huge issue that we must test and try various models. There is no silver bullet. While Practicing Physicians will encounter a bumpy road, we must all pitch in to make our views known and heard.