BIG Ideas from The Business Intelligence Guy

Today’s BIG Idea comes from data analysis projects I do for healthcare consultants.  This consultant is working with a group that outsourced their billing and then had revenue cycle challenges.  Today’s podcast describes an unusual challenge — the billing company was not consistently and correctly charging the billed charge per the fee schedule.  The podcast describes how we used Excel’s Pivot Table feature to track variances in billed charges.  You may be very comfortable that your billed charges are going out correctly, but the bigger question is what parts of your revenue cycle do you assume are being done correctly that are not?  Where are the holes in your revenue cycle?  I hope these podcasts give you something to think about.

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Today’s BIG Idea is from a practice in the Midwest who had a payer deny a claim because the pre-authorization was for one day and the day of the procedure moved.  Are pre-authorizations giving your practice headaches, too?  Listen for ideas from both AthenaPractice and AthenaOne on how to build an exception report to track appointments that may be a problem.  The first step is to reliably filter those appointments to only find appointments that need pre-authorization.  That may take standardization and consistency from your scheduling team.  The second step is to data mine to find appointments without authorization.  Some pre-authorizations are based on dates and other authorizations are based on procedure count.  Some patients have more than one appointment/procedure that needs authorization.  Matching the right authorization to the right procedure takes work.  Standardization really helps.  The process is not easy, but catching even one procedure that is has a missing or an expired authorization is well worth your time.

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Are you tired of seeing payments reduced due to advanced practitioners and incident to billing rules?

You are not alone.

Today’s BIG Idea is from a group of general surgeons in the Midwest whose policy is for physicians to review advanced practitioners’ charts to ensure maximum reimbursement.  The analysis in the accompanying graphic shows some of the analysis we did to determine which surgeons had the opportunity to review the advanced practitioners’ charts, which advanced practitioners most frequently did not get their charts reviewed, and the procedure codes most frequently reduced by failing to comply with incident to rules.  Listen to the podcast for ideas on how we made the analysis work and how something similar could save your practice a considerable amount of reimbursement.  I hope you find incident to billing opportunities in your practice.  Thanks for listening.

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Are you missing patients?

Today’s BIG Idea podcast is from a Rocky Mountain practice who wants to find patients that should have been seen by now but do not have a future appointment.  The idea to look for patients you expect to have followed up with in a certain time period is common to many specialties and can help retain patients you may lose.  After all of the marketing efforts you expend to invite patients to your practice, do not lose them by failing to help them follow up with your providers.  The podcast also discusses how the report can be customized to choose how far back to look for patients you should have seen by now.  By combining a macro-enabled spreadsheet with an input cell and a text box, you can add power and flexibility to your spreadsheets and your analysis.  I hope these podcasts help your practice.

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Is estimating patient charges time consuming for your practice?

Medical practices are used to good faith estimates, but what if a self pay patient’s charge is more complex than a simple procedure code?  Today’s BIG idea is from an orthopedic practice that wants to estimate more complex patient charges.  Their idea is to grab all patient encounters with a given procedure code on the encounter, then use that historical data to estimate a patient’s charges and payments based on all encounters containing that procedure code.  The podcast will give you some ideas about aging the claim to ensure the claim has had a chance to be paid and some ideas about how you might use this data.  How would your practice use data like this?  I hope these podcasts give you ideas to make your practice better.

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Still thinking about payer transparency data and knowing what your competitors are getting paid?

So am I.

Today’s BIG Idea is an overview approach to what competing medical practices are getting paid.  The example is from an orthopedic practice in the Boston area.  I took 5 major procedure codes and compared what Anthem is paying competing providers in four counties around Boston.  The graphic accompanying the podcast shows orange for the highest contract for the provider I chose and blue for competing practices.  This market overview report shows this practice is at the lower end of the scale for all 5 procedure codes.  Note that for some codes there is a wide range of maximum contracted amounts and for other codes the range is more narrow.  Either way, this practice is toward the bottom of the scale.  As I play more with this data, today’s market overview report may be an ideal place to start with this payer transparency data.  I said this the past two weeks and I will say it one more time.  There is real opportunity in understanding and leveraging this data.  Thanks for joining me.

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Did you find last week’s podcast about payer transparency data interesting?

Today’s BIG Idea is another way to look at your practice’s competitor’s contracts.  The graphic accompanying the podcast shows a OBGYN practice in Central Florida and how contracted rates vary widely in two counties.  The benchmarking report shows where the practice’s contracts fit across all published contracts for that procedure code in that area.  Listen to the podcast to hear why there are multiple contracted rates shown in the chart and why the highest rates shown may not be the most common rates paid.  Even if your practice cannot negotiate your rates to the highest level, even moving up from one column in the histogram to the next may mean over $500 per procedure.  Per patient.  There is real opportunity in understanding and leveraging this data.  I hope you find these podcasts helpful.

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Are your competitors being paid more for procedure codes than your practice is?

How much more?

Happy 2024 everybody.  I am playing with a new toy this year.  Insurance carriers are required by law to publish contracted rates by procedure code, but they have made it very difficult to access those rates.  Until now.  Would you like to see contracted rates by procedure code, payer, NPI number, and more?  I have an example of the data in the graphic accompanying today’s podcast.  You will see major procedure codes for an orthopedic practice and a competing orthopedic practice in the same market.  This analysis compares Anthem, Cigna, and United rates for those top procedure codes for the two practices.  Interestingly, for these codes in this market, Anthem is paying the two practices the same rate.  That is not true for Cigna and United.  You will some wide discrepancies between the two payers for the two practices.  For the same service.  How would this data change your payer contracting?  How would knowing what competitors are being paid influence your strategic plans, whether that means expansion, mergers, or major changes in your practice?  This data may drive the most important decisions and the most profit to your practice this year.

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How long has it been since you analyzed your practice’s revenue cycle?

Today’s BIG Ideas podcast describes several steps I use when analyzing a practice’s revenue cycle.  Listen for the data I gather and for a general approach to get started.  The graphic on my web page shows several columns you might build in a Pivot Table analysis.  I start by looking at the major procedure codes for the major payers.  Then I build columns to look at charge dollars, the average charge, the total number of units billed, the allowed percentage, the allowed amount in dollars, and the amount paid in dollars.  There is more information in the podcast, but you would be surprised how often billed charges or allowed amounts are not consistent.  There are also payer contracting insights gleaned from analyzing a revenue cycle using this approach.  Watch for an example in the graphic where the average payment is more than the average allowed amount.  What could be causing this?  

How healthy is your revenue cycle?  Are you sure?  In today’s medical practice environment, you cannot be too sure.

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Recent podcasts have discussed tracking how patients come to your practice and how patients leave your practice.  Today’s podcast is from one of my sessions at the recent MGMA Leaders Conference in Nashville about following patients through your practice.  Which provider does the patient see first?  What procedure codes and diagnosis codes are on the first visit?  Where does the patient go next?  How does the path the patient travels through your practice influence their care and your revenue cycle?  Does the first provider seen impact how long it takes for the patient to be eventually treated?  I hope these ideas help you and your practice.

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