Prior authorization

Another area in which medical offices can trip up is not obtaining prior authorization, Hays said. Practice management systems should have a way to identify which claims prior authorization denials were attached to, what information the practice office should be submitting but is not, and the process for obtaining prior authorization for each scenario.

Practices may be able to create a process that flags claims that need prior authorization before the claims are submitted to ensure the appropriate information is attached.

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“This is something that isn’t just always up to the front desk, it’s a team effort,” Hays said. “It’s not just billing, but nurses and physicians all need to know that just because they do a procedure, it doesn’t mean they are going to get paid for it.”


Hays also recommends a report that checks for high write-offs. Creating this report can inform practices of payers that have write-offs higher than 50%, which Hays said should throw up red flags. In these cases, these payers’ fee schedules can be pulled to see where the discrepancies lie. 

For instance, if the negotiated rate is $80 for every $100 charged, and they are using a write-off of $40 for each $100, the payer should be contacted to find a resolution. “Twenty dollars out of $100 is a big chunk of change,” Hays said.

Fee schedules

Fee schedules are something that most practices do not take the time to enter into their system, but practices would benefit from doing so, Hays said. For example, if a contract with a payer says it is supposed to pay a practice $140 for a specific code, most electronic medical records (EMR) systems issue an alert and create an exception report if payments are less than the expected amount.

Hays also recommends keeping abreast of the costs of medications and supplies. Prices can fluctuate, and if reimbursement rates do not at least cover these costs, a practice can end up losing money.

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This article originally appeared on Renal and Urology News