First, have your EMR system (or billing company) print an Ageing Report for the period you wish to review; split this into both Plan and Guarantor A/R.  I recommend this be done monthly, with a quarterly roll-up report to review for trends. Second, compare this to the previous time period, and note if there are any adverse changes.

 

Pay particular attention to (1) the 0 – 60 day age (cumulative) range, and (2) the over-90 day (cumulative) range. I like to see at least 60% of total A/R under 60 days, and no more than 20% over 90 days.  This is highly dependent on the specialty and the mix of health plans. For example, an Orthopedic Surgeon specializing in hip replacement who has a mix of 80% Medicare patients would expect to have a much higher proportion of A/R in the 0 – 60 day range, as Medicare tries to pay its billings within 14 days of receiving a clean claim.  A Family Practice physician with a 15% mix of Medicare patients would have far less in the 0 – 60 day range.

 

Look at each of the major plans to see if there are significant changes over time, and if there are, drill down to the individual EOB level to determine why the A/R has stretched out.  Is it the result of one large account being held up, or is there an overall slowdown in payments?

Yes – (1) if you are new to Medicare and this is your first year, or (2) your Medicare volume is less than $90,000 per year and/or (3) you see less than 200 Medicare patients per year, then you do not have to participate in MIPS.

No – Medicare, private insurance companies and state insurance regulators view a waiver or discounting of co-payments to be an inducement to commit fraud. Copayments are intended to prevent over utilization by patients. If you waive these, or significantly discount them, absent significant efforts to collect, you could be in violation of your health plan contract and state law.

 

Discounts are very expensive to implement; to be effective, they are normally in the 20% + range. I only recommend using them once per patient as an alternative to sending the account to a collection agency.

Most EMR systems send out billing statements (generally 2 – 3) over a 60-day period to patients after an EOB has been returned by the payor (insurance company) specifying the amount the Guarantor owes. If not all the money has been received, it is then placed in the A/R buckets for the client to work.

 

I recommend the medical practice work this no longer than 90 days after it has been worked by the system. If you cannot get payment, or have not been able to set up a payment plan with the patient by that time, it should go to a collection agency. However, if early on it becomes evident the patient will not pay (a verbal notice of non-payment, refusal to return phone calls, etc.), then sending it to a collection agency sooner is warranted.

Yes – and these should be given to each new patient. They should clearly outline that payment of co-pays and co-insurance is due at the time of service, and that additional billing may be made depending on the health plan’s determination. Note what happens when a bill can not be collected (the patient may be discharged and the bill sent to a collection agency).

 

Stay away from tacking on interest penalties; most plans prohibit this, and they are very hard to collect. If the patient is not going to pay his guarantor amount, it is not likely he would pay interest.

For patients who have a large copayment or coinsurance, the practice may wish to set up a payment plan over time. Try to collect 50% of the outstanding balance up front, and the remaining 50% over a 6-month period of time. Note in writing (in the “notes” section of the billing module) the date the arrangement is made, the start time and amounts, and the patient’s telephone number.

 

Try to get a credit card on file, and an agreement to run it on a date defined every month until the balance is paid off. If the patient fails to pay according to plan, give him a chance to catch up within 1 – 2 weeks. If that does not work, reinstate the bill and send it to a collection agency.

Sending a bill to a collection agency should be done as a last resort. Most agencies charge in the range of 35% of the amount collected, are successful in collecting only about 10% – 20% of the amount due, and work accounts for no more than 120 days.

Generally, plan on at least 9 months to get a new graduate in your practice. Most residents graduate at the end of June and are available for work the first part of August. In order to get a new physician on board on August 1, 2020, you should plan to have an offer to him / her in early November 2019.

No – Medicare regulations (Medicare State Operations Manual, Appendix L, Part II, §416.2 Definitions) state:

“Ambulatory surgical center or ASC means any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following and admission. ”

 

“An ASC satisfies the criterion of being a “distinct” entity when it is wholly separate and clearly distinguishable from any other healthcare facility or office-based physician practice…..it must be separated from other facilities or operations within the same building by walls with at least a one-hour separation.”

 

CMS permits certain common, non-clinical spaces, such as reception area, waiting room or restrooms to be shared between an ASC and another entity, as long as they are never used by more than one of the entities at any given time...In other words,…the common space may not be used during concurrent or overlapping hours of operation of the ASC and the Physician office.”

Effective September 1, 2023, the federal 21st Century Cures Act states that medical records used for treatment, payment or healthcare operations purposes must be provided to the patient at no cost to the patient.  While patients may not be charged for reproduction of their Protected Healthcare Information (medical records or financial records), other entities such as attorneys may be charged a fee, which is capped by the HIPAA privacy rule.

Arizona law (ARS 12-2295 B.2) states “a healthcare provider…shall not charge for the pertinent information contained in medical records provided to…the patient to whom the medical records pertain for the demonstrated purpose of obtaining health care.”  So in Arizona, a provider is not able to charge a patient for medical records, but may still charge an insurance company or lawyer for them.

Source:  Modern Healthcare Connection, January 2024, “Release of Information: What you don’t know can cost you” by Shelby A. Dodd, pp. 92-94, and “21st Centaury Cures Act” as published in the Federal Register edition of November 1, 2023.

The following reports provide key metrics to evaluate the business operations of a medical practice:

 

Monthly

• Profit and Loss (” P & L”) statement compared to the same time last year, with a column for dollar difference and percent difference
• Balance Sheet for the current period
• Roll-up P & L (starting from January through the current month, i.e.; January – March, not broken out by month) Statement
• Roll-up Balance Sheet
• Billed Charges and Collections
• Revenue lost and delayed by number and amount of billed charges)

Quarterly

• A/R Ageing summary (lump all payor sources together) report broken down by (a) total, (b) health plan and (c) guarantor
• Procedure summary report by CPT listing (a) CPT, (b) charges (c) units and (d) collections. Use this report to evaluate E & M coding and compare to national standards (what % of NP E & M is level 5, level 4, etc…, same for Established E & M)

Every 6 Months and as a Yearly Summary

• Physician Referral Summary Report by referring physician (list only gross referrals, do not break down by patient)
• Billed Charges and Collections summary report by major insurance carrier (list only total numbers; do not break down by individual plan or patient listing. The idea is to understand market share for each plan)

 

The reports that roll up monthly or semi-annually (P & L, Charges and Collections, etc…) will include all months from January onward in the December report.