Medical Billing

So, you got on insurance panels. You opened your practice. Now, how do you actually bill the insurance and get paid?

Obviously, the point of medical billing is to get paid for your work. But what is reasonable to expect?

Answer: You’re doing well if you receive 96-99% of claims, or money from claims. I make this distinction because if you’re billing for different services and you’re getting paid on your small claims, but not your high-fee claims, you could potentially have a high percentage of claims paid, but a lower percentage of total money in the door.

A quick note: having 100% of claims paid is always what you’re aiming for–that would be ideal. But because the healthcare system is unfortunately imperfect, you should be satisfied if you’re receiving 98%.

Consider it a red flag if you’re receiving under 95% of your claims.

If you’re at 94%, don’t panic, but it’s time to look closely at your reports and determine where you’re losing that 6%. That way, you can make the necessary changes before it gets worse.

If you’re under 90%, it’s definitely time to hit the panic button and seriously evaluate what’s going wrong.

The thing is, many practices collect less than 90% of what’s owed to them without even knowing it because they don’t have reliable reporting. Being able to run reports and determine where your money stands is a must—even for a small practice.

This leads us into Question #2:

Do you know what has been paid (or not paid) and why?

There are always going to be a few unpaid claims, and there are a lot of reasons why a claim can go unpaid. We recently published an article titled 17 Reasons Your Insurance Claims are Being Denied.

Reasons can range from the client not telling you that they changed their insurance to forgetting about preauthorization. Or perhaps the client had a deductible, and they never paid the bill!

If you, or the person doing your billing, doesn’t understand why claims are being unpaid or how to fix the problems, I guarantee you that money is being left on the table.

The person responsible for your billing should be able to sit down with you and tell you the status of every outstanding claim. There should be no mystery.

A red flag is not knowing why you haven’t been paid. Hit the panic button if you don’t know what’s been paid!

Question #3: how many days are Receivables Outstanding? In other words, what is your DRO?

Under normal circumstances, you should expect payment within 45 days. Some insurance companies pay much faster; about a week is on the fast side! But legally, companies are allowed 45 days to pay.

The #1 reason that claims are delayed is because the claims were not submitted timely. A good billing company (or in-house biller) should generally get your claims submitted several times a week.

The other reason that claims can take a long time to be paid is if they are not submitted to the right managing company. Sometimes, insurance companies take some of their services, such as behavioral health, and have another company manage them. If you submit a claim to the wrong company or department, the claim will usually be paid, but it will get bounced around for a long time first.

Consider it a red flag if your DRO is over 65 days. Hit the Panic button at 90 days!

Finally, whether you’re working with a medical billing company, or doing your billing in-house, remember these three final takeaways:

1) Don’t allow too many excuses
2) Require specifics from your biller
3) Use automated reporting – there are a number of systems on the market for this, and it’s absolutely worth the investment, even for a small practice.

We at Thriveworks would love to help you with medical billing.

We offer full-service medical billing at affordable rates. Our story is that we started as a medical practice, and after many years perfecting our billing process, we began offering help to other practices. We don’t want you to have to reinvent the wheel. In fact, we’re confident that most practices that sign up with us end up saving money immediately, as well as their staff’s time.

Call us anytime for more information! We’d love to answer any questions you have. 1-855-4-THRIVE


Dr. Anthony Centore
And your friends at Thriveworks