Case Study
Situation before CAPRN
In October of 2008, an office of seven behavioral health professionals was experiencing severe cash flow problems. The office had high turnover in both the front and back office staff. The physicians were not able to collect more than 50% of their medical billing. As a result, receivables had grown substantially.
Enter CAPRN - The Analysis
As of November 1, 2008, CAPRN was invited to come in and begin an assessment of the situation. We assigned a staff of three medical billing personnel. After reviewing the EOBs, calling on outstanding receivables, observing front office procedures and gaining an understanding of the daily processes of the practice, CAPRN identified seven key issues that could immediately address a majority of the medical billing problems. These were:
- Front office staff were not following through with procedures to ensure that patients were properly authorized nor verifying that the patient insurance was valid at the time of service (each time and not just once a year).
- Medical billing staff were processing on multiple websites and not using a central practice management system to record charges and payments. Billing staff was using the Cigna, Aetna, and other insurance sites with no centralized accounting of the claims.
- Staff did not have the time to manage denials and outstanding claims as they were understaffed considering the patient load of the practice.
- Front office had no training on current fee schedules, deductibles and the allowed amounts per the contract.
- No controls were set up to make sure that all patients seen on the schedule were actually billed. Many patient charges were not billed due to missing superbills that would be misplaced in a chart or in the doctor's offices.
- No good communication process set up with the hospital to obtain the proper authorizations and information for inpatient claims. Many claims were not being billed at all.
- Doctors were selecting CPT codes and diagnosis codes that were neither authorized nor reimbursable per their specialty.
Based on our assessment, CAPRN simultaneously started working with the front office operations and the backlog of claims.