Most practices lose revenue in ways that never show up as a single problem. Small underpayments, unworked denials and missed calls add up. Use this checklist to find where money may be leaking in your practice.
The checklist
- Underpaid claims. Payers paying less than your contracted rate. Compare remittances (ERAs/EOBs) against your fee schedules by payer and code.
- Denials that are never appealed. Track denial rates by reason and payer, and set a rule for which denials are always worked.
- Expired or outdated payer contracts. Know when each contract renews and whether rates have kept up.
- Missed prior authorizations. Especially for biologics and infusion, a missed or expired authorization can mean an unpaid claim.
- Eligibility not verified before the visit. Coverage changes lead to denials and patient balances that are hard to collect.
- Unanswered phone calls. Every missed call can be a missed appointment, a delayed authorization or a patient who goes elsewhere.
- Coding and documentation gaps. Services performed but under-coded or not documented to support the code billed.
- Patient balances left uncollected. Collect copays and estimated balances at the time of service.
- Drug acquisition costs. For infusion, purchasing terms and reimbursement should be reviewed together.
- Services your patients already need. Referring patients out for services, such as infusion, that the practice could safely provide itself.
Where to start
Start with the first two items. A payer-by-payer comparison of what you were paid versus what you should have been paid usually reveals the fastest wins.
KVLR Capital offers independent practices a complimentary revenue review that does exactly this, with findings in dollars and no obligation.