Home » Blog Articles » Denied Claims » Independent & Private Medical Practices: 4 Common Problems

Increasingly health systems are turning healthcare providers into salaried employees. Yet, some physicians and other healthcare professionals would like to be their own boss. Providing services as a private or independent practice can achieve this goal, but there are challenges.

Building and working in private practice can create problematic situations. Yet, healthcare providers want the best setting for themselves, so that they can deliver high-quality care to their patients. With this in mind, here are 4 common pain points for healthcare providers running and working in an independent or private medical practice:

  • Medical billing
  • Finding the proper EHR
  • Insurance credentialing
  • Negotiating contract rates

[1] Medical Billing Complexities:

A major goal when processing medical billing is to generate clean and accurate claims for submission to insurance payers. Once these claims are submitted, they should be tracked and monitored by back-office billing staff. It is always essential to know what claims have actually been paid. A well-organized billing flow will streamline a practice’s back office and allow for a more optimized workflow.

However, a medical practice can find itself spending too many hours and resources on managing their billing process. Medical billing, or revenue cycle management, is more complex than some healthcare practitioners realize.

Tasks like prior authorization are easier to complete when staff members know the precise rules to use. Otherwise, obtaining prior authorizations can become a time-consuming task. Office staff must be familiar with an insurer’s formularies, which then saves patients and healthcare professionals time and money.

If the person assigned to billing is not familiar with policy guidelines of each insurance payer and coding requirements, submitting claims becomes time-consuming and drains valuable resources away from a practice.

Having quality office staff will improve patient collections. This includes active denial management due to the fact that denied claims are a problem for many billing departments. The goal of denial management is to reduce denial rates to as low as possible.

[2] Finding the Proper EHR:

Whether a medical practice is using an electronic health record (EHR) or an electronic medical record (EMR), a common complaint is that these systems are sometimes difficult to use. EHRs (or EMRs) are a potential pain point for many clinics and practices due to ease of use issues. Some EHR’s are sometimes time-consuming to use, inefficient and expensive.

Healthcare providers may actually use or experiment with many EHR systems, before they find one that suits their needs and is affordable. There are almost always pros and cons with any EHR or EMR system. In addition, how practitioners use EHRs has generated both lawsuits and reports of patient dissatisfaction.

However, there is a start-up advantage for new practices who are beginning with a new system. This beginner’s perk is due to the fact that a new practice does not need to migrate patient data from the old system. When a new practice picks up new patients, they only need to load the patient’s data one-time into the system. This saves considerable time and money.

[3] Insurance Credentialing – Revalidation, Re-attestation & CAQH Updates:

Medical credentialing is a process that all successful medical practices need to master. Otherwise, denials and aged claims will create significant cash flow issues and other headaches. In addition, patients will see the healthcare provider as being out-of-network, which increases a patient’s out of pocket cost for medical procedures.

Proper credentialing procedures has physicians and other healthcare professionals regularly submitting documentation to every insurance provider that they wish to receive reimbursement from as an in-network provider of medical services.

Successful medical practices need to successfully track credentialing requirements and updates. However, navigating through questions, applications and terminology is a challenge for many healthcare professionals. This is where a dedicated credentialing specialist can help.

At times this is complex and time-consuming task that needs to be monitored by office staff. Ideally, a clinic or practice should have a dedicated credentialing specialist(s) who can track items like re-attestation and revalidation updates. A good credentialing specialist is a valuable member of any modern healthcare team.

A skilled credentialing specialist will confirm that there as few delays as possible in the credentialing process. This includes directly communicating with healthcare providers as well as tracking information updates from CAQH, PECOS, NPPES, etc.

[4] Negotiating Contract Rates:

Some healthcare professionals are surprised to learn that contractual reimbursement rates are not uniform for all healthcare practitioners and organizations. At times, attempting to negotiate with insurance companies is tedious and frustrating. Some insurance representatives are unsympathetic to independent practitioners needs or even rude and obnoxious.

Over time, independent healthcare providers can grow their practices. With enough patient volume, they can sometimes achieve a beneficial rate from the insurance payers. However, this usually only after healthcare providers have numerous locations with a substantial volume of claims to submit. For healthcare providers with smaller locations

In this case, independent practice association member practices can help when negotiating with insurance providers. The greater volume of submitted claims provides an association with more leverage when negotiating their insurance contract. In many situations, the more claims an association can potentially submit, the more potential leverage they will have when negotiating the next insurance contract.

Simply put, when legally negotiate rates and contract terms collectively with health plans, there is strength in numbers. Naturally, meeting with an experienced attorney can help avoid any possible antitrust problems.

For More Information:

Advanced Billing & Consulting Services (ABCS) provides experienced medical billing and credentialing services for a variety of healthcare practitioners. Their billing and credentialing specialists offer revenue cycle management (RCM) solutions that streamline a medical practice’s billing, coding and claims processing tasks.

Contact them in order to learn how they can optimize the medical billing process while saving practices on their back office administrative costs.

Follow on Twitter: ‎@abcsohio

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