What Makes Practice Administrators Say “Really?”

When I graduated nursing school and started my career as a healthcare provider, I believed in something that I and many other clinicians saw every day: a cause and effect mentality. As a clinician, if I provided a specific treatment or intervention (cause), then there was a specific way the human body would typically respond (effect). There were exceptions (as there always are), but the general rule was sound.

And then I transitioned into healthcare management and encountered medical billing.

With medical office billing (and speciality practice billing specifically), it was like I’d stepped onto another planet, where the laws of physics I’d always known to be true no longer applied. The cause and effect logic went straight out the window. During the early days as a practice administrator, I’d find myself stopping, raising an eyebrow, and muttering, “Really?” Is this really how things work? And should this be the way things work?

There’s a whole lot of illogical, even inscrutable stuff that happens in medical practice. Let’s take a look at four of the many scenarios in billing and healthcare management that can make even the most seasoned practice administrator take a few steps back, scrunch their nose, and ask, “Really?”

4 Scenarios That Make Practice Administrators Say “Really?”

These are four scenarios familiar to just about every practice administrator. As you read, know that there is a better way — one I’ll show you by the end of this blog post.

1. You don’t know what (or when) you’ll be paid. Really?

Imagine this scenario (it won’t be hard because you’ve probably lived it within the last year, maybe even within the month!): you bought a monumentally expensive pharmaceutical because it was the right choice to provide a cancer patient with the treatment most likely to achieve the needed outcome.

You’re pretty sure you’ll get paid for this pharmaceutical eventually. But you aren’t certain.

Worse, you have no idea how much you’ll get paid — or when.

• What if the pharmaceutical is underwater with the patient’s insurer, and your practice loses money to provide lifesaving care?
  
• What if a payer takes months to pay, leaving your practice on the hook for hundreds of thousands of dollars of real bills due that you haven’t yet been paid for?
  

Does it make sense that this should be normal, the status quo? I don’t believe so, yet this is the way most practices operate. If you’re the practice administrator and you’re saying “really?”, you’re right to do so.

2. You followed all the rules, still got denied, but still work with that payer. Really?

Here’s another one that might hit a little too close to home.You sent a clean claim to a payer: you followed every last billing guideline, no matter how convoluted. You jumped through hoops, dotted Is and crossed Ts, signed in blood — and yet, for no clear reason, you were denied.

At this point you might be thinking, “Right, sounds like a normal Tuesday. What’s your point?”

After getting denied despite doing everything right, do you keep doing business with that payer as if nothing went wrong? Most practices do. And most practice administrators, when they see it with this level of clarity, stop and say, “Really? Is this the right way to do business?”

3. You aren’t paid according to a contracted fee schedule and see this as normal. Really?

You’ve got a signed agreement with a contracted fee schedule. That’s supposed to be binding, but is it? Many payers seem to ignore these agreements and fee schedules, paying on their own timetables (or simply not paying at all). And many practices accept this as normal business, the status quo, just the way things are. Really?

What’s the point in having a contracted fee schedule or signing an agreement if it doesn’t have teeth? If it’s unenforceable, then it’s little more than a waste of time.

Of course, there are reasons why this happens. A practice has to know that it didn’t get paid according to the contracted fee schedule. At scale (and without the right set of digital tools), this is hard, if not impossible, to keep up with. If you lack the mechanism or capability to stay on top of fee schedules, relying on payers to pay (and hoping they do so on time) does become the norm.

4. There are zero repercussions to payers who take too long to pay. Really?

As you go about sending claims to payers, you get responses that vary in terms of timeliness. Some payments roll in after 14 days; some after 60. (And some get denied altogether, like in scenario #2.)

Most of the time there’s no functional difference to the payer if they pay at 14 days or at 60 (or later). There are no impactful repercussions for late payments or bad behavior. And practices accept this as normal. Really?

It ought to be possible to create and enforce penalties or repercussions for late payments. 

Your Best Defense Against the “Reallys”

Across these four scenarios (and countless others like them), there’s a common force at work: the status quo.  Things are the way they are in medical billing. But technology is changing what’s possible, which means now practices have the ability to shift that status quo. We see three strong defenses against this status quo (and the “reallys” it generates).

Solid Contracting with Built-in Repercussions

Your first defense against the “reallys” is creating better, more solid contracts and building in repercussions. It’s possible to flip this script and show payers you will hold them to their signed agreements and contracted fee schedules, but it requires two things. You need contracts that spell out what the repercussions will be, and you need the ability to track and automatically act when payers fail to live up to their contracts.

Validated Fee Schedules for All Payers and Plans

Second, you need validated fee schedules for all payers and plans that are continuously monitored and consistently uploaded into your practice management system so that there’s no doubt what payments you should receive for various pharmaceuticals and procedures. This often isn’t feasible for most practices using manual processes.It can be possible with the right systems in place.

Line Item Auditing of All Transactions

Last, line item auditing is the way to identify errors in real time so you can easily recognize non-payment or underpayment scenarios. With the right system in place, you can identify errors quickly and serve them back to payers as soon as possible. You then have the ability to prioritize claims based on which are the most likely to be paid the fastest and which represent the highest amounts of money to be repaid.

Start Turning “Really?” into “Really!”

At AC3, we believe it’s long past time to bring medical billing into the twenty-first century. We understand what an undertaking this is because we were founded by practice administrators who were living these “reallys” every day -- out to solve them.

AC3 is a unique mix of next-gen technology and hands-on service. Our Revenue Cycle Managed Services and our Contract Intelligence and Payment Integrity services are transforming the way oncology practices approach billing, saving time and resources while exponentially increasing recovered payments.

Ready to see AC3 for yourself? Request your personalized demo now.