Open Icon Key

Verification: The Keystone to a Great Financial Department

3rd Party Billing and Collections
Rhonda Hodge MCS-P
in 3rd Party Billing and Collections

Verification: The Keystone to a Great Financial Department

Verification is the Keystone to a Great Financial Department

We are often asked, “How can I make my financial department more productive/efficient/profitable?” One thing is clear: it is not just a select group of providers that are dealing with these concerns. It seems to be a pervasive issue throughout the profession. And we’re here to help!

Where Do I Start?

When these queries come to us, one of the first questions we ask is, “Does your staff perform a verification of benefits?” Surprisingly, or maybe not, the answer is often “no” followed by one of the following explanations:

  • We already know what the benefits are because we have many patients with the same coverage
  • I wasn’t aware that I had to do that
  • The patient stated he/she contacted the carrier and already knew what the coverage was
  • We are not in network with the patient’s carrier, so we don’t verify the coverage

Step 1: Implementation

The verification process is the keystone of a great financial department. By leaving this step out of the financial process between you and your patients, you could be putting your office at great risk. This simple, yet often time consuming step sets the tone for every other financial transaction. It provides a very clear picture of who is responsible for what portion or payment of the services rendered. When financial expectations are clear, better patient relationships and treatment plan compliance result.

Implementing the verification process in your office will ensure that your financial team (biller and front desk) are set up for success, proficiency and profitability. Your Front Desk staff will have confidence in the accuracy of the account balances and collect appropriately for the services provided. Your Billing Department will be more confident that what is being billed to the insurance carrier is correct and meets the carrier’s expectations. And should a denial for payment occur, or an inaccuracy of payment happen, the biller will be better equipped to contact the carrier with complete information to appeal or inquire about the issue. In many instances this may be the difference between getting payment or not.

Step 2: Medical Review Policy

For every carrier that you work with, whether in-network or out of network, you should have a Medical Review Policy (MRP) on file. Each carrier will have an MRP, generally available on the carrier website, although some may have to be obtained by contacting the carrier. The MRP outlines how the contractor reviews claims and documentation. This understanding can help ensure that the coverage requirements are being met. CMS requires MRPs to be consistent with national guidelines (although they can be more specific), developed with scientific evidence, backed by clinical practice and developed according to certain specified federal guidelines.

The MRP helps you and your staff recognize and understand why a carrier might pay, deny, or request documentation of a claim based on the codes billed. This includes the carrier’s definition of Medical Necessity, and what documentation is required to substantiate the need for care and therefore payment.

Regardless of what format you retain this information in (paper or electronic), it is worth the time to review and highlight areas of the MRP that will directly affect you and your practice. The best way to find the MRP for the carriers that you interact with is to perform an internet search for that specific payer’s MRP.

Step 3: Understand the Guidelines

Every carrier, including Medicare, publishes their Local Coverage Determination (LCD). The (LCD) contains information regarding the Current Procedural Terminology (CPT) codes and Diagnostic Codes that the carrier will allow. It also provides information regarding modifiers, definitions of maintenance, acute, chronic, etc. (as it pertains to treatments being approved by the carrier), visit limitations, documentation requirements (for initial & subsequent visits), requirements for imaging, and much more. Since Documentation guidelines require a recommended level of care including specific treatment goals and objective measures to evaluate effectiveness, knowing each carriers’ expectations of these guidelines is like having the instruction manual or playbook.

Compliance guidelines are being enforced more and more

Ensure that your office has steps in place to increase your accuracy and compliance. You will reduce stress and worry, improve collections, reduce outstanding A/R balances and at the same time provide valuable information for your patients regarding their responsibilities and what they can expect from the carrier. Patients gain confidence and trust in your care and may just become better sources for referrals.

Wouldn’t it be great if you could implement this one element (all three steps) and make improvements in all those areas? You can. You can start today with this process by reaching out to KMC University and becoming a member. We have the tools and assistance you will need to make this a successful transition.

Read more KMC University Blogs

Rhonda Hodge, MCS-P began her career in Chiropractic in 2000. She has extensive experience with the regulations, training, and guidelines associated with the Occupational Safety and Health Administration (OSHA). She is also very well-versed in Safety and Loss Prevention and is currently focused on Compliance. Rhonda became a Medical Compliance Specialist – Physician (MCS-P) in 2012—the year she joined KMC University. She has helped clients complete Medicare Enrollments for their patients and written curriculum and training webinars. Rhonda has extensive experience with finances, front desk operations, training, billing and collections, Medicare, and compliance.