We have all heard (at least folks my age), “If I had a dime for every time____” and then fill in the blank. In my case If I had a dime for every time I heard “My ambulance billing service or my ambulance biller collects everything collectable and never leaves anything behind”, I would be rich. The fact is that in most cases, it is simply not true. What is worse is that management or accounting are not aware of that fact. They often have no ability to track anything other than that collection rates seem to be the same, or that the amount of cash collected is the same. But is “the same” good or bad??
The reason it is not true is actually fairly simple. That last 10 to 15% of the revenue in ambulance billing takes as much work as the first 85 to 90%. There are many reasons for this, but it usually boils down to the simple fact that denied claims, claims without proper insurance, claims without the right member IDs, claims that are difficult to collect from payers and other variances from the norm create an enormous amount of work.
These more difficult claims create the conflict in resourcing the billing department properly. In general, management or the billers themselves realize that they’ve processed almost 100% of the bills and have probably been paid by 90% of the claims. All this is likely filling up the work day, and often they don’t have time to properly work to completion those last 10 to 15%.
Everyone does some work on denials or rebilling claims or attempting to find proper insurance information, but almost everyone comes up short in that effort. It logically seems unproductive to increase your staffing level so much more to handle 10 or 15% of the transports. The natural inclination is to think I need to work 10% more to handle 10% more of the claims. But that 10 or 15% takes a significant amount more to work than the other claims and often is a significant lost revenue stream. That lost revenue stream in a private ambulance company can often be more than the profit margin. And even in government EMS billing departments, that is a significant amount of lost money for the organization.
How do you ensure that extra 10 to 15% is actually collected? The easy answer is to do the additional work required; however, that often takes too much time without the assistance of an excellent software product. That product would be developed in a way that allows you to easily identify the unpaid claims and more importantly automates a lot of the current manual processes to provide adequate time to the billing department to work them. Lastly, it must provide oversight for management.
During, the last seven or eight years , while upgrading billing systems to our more advanced software product, we often did a data conversion of the previous software’s data.
Almost always our more advanced reporting system would immediately identify 10-15% of the transports that, even though those claims had insurance, had never been paid. This was not the exception but the rule in doing close to 100 conversions.
The common theme was always surprise at the number of unpaid claims, and the “reason” the claims were never collected. The reasons included issues such as missing information on that claim and no time to rework them, and/or the previous system had not easily identified those claims.
Many times they had been billed properly but a payment or denial never occurred, and a simple rebilling would have quickly changed the status to paid. Obviously that is a problem with the insurance companies but we cannot fix that so better to deal with the problem.
Another common theme was that management or accounting departments had no way to actually audit the billing department and review such claims and request information as to why these claims were not paid. Without such oversight or ability to work in partnership with your billing department to manage this issue, there was simply no visibility of the need.
In discussing with management and/or accounting departments I often heard “our collection rates have been steady”. This comment to me made it clear they’d never been successful at collecting the last 10 to 15%, and again had no way of knowing they could have. The key is the ability to know what has happened with each and every bill in the system at any point in time, coupled with the knowledge as to what is being done to collect them. Sometime it is legitimate to give up and realize it is uncollectable. In that case however the transports should be flagged and coded as to why. Statistical tracking of that can also be useful. But I would still add a caution, management should review even these to ensure they were truly not collectable. One person’s uncollectable can be collected with a different process. For example, claims flagged as uncollectable can often be rechecked for insurances like Medicaid, which may not always be found on the first eligibility check but can be found on a retry a few months later.
While this problem can always be solved with more resources in the billing department, a better more efficient way and more likely to be successful is through automation and review of the processes to rework these claims.
Areas of automation that make a difference and provide needed time for the billing department to work these more complex claims begins with automation of routine tasks. Some examples of such automation include: basics such as automatically importing electronic payment EOBs, using a system that moves denials from these electronic EOBs into a “bucket” to be reworked, using a system that identifies claims crossed over to another payer from Medicare (and some Medicaid systems) to track that additional payers payments, and many other processes that can be automated (too many to mention them all here).
More importantly is a simple but powerful reporting system that can easily identify all claims over a certain amount of days since being billed and the insurance has not made a payment.
Even better is a system that knows the typical time that each individual insurance company pays and alerts the billers to claims that are not paid in the timeframe, maybe even putting them in a “bucket” to be reworked.
That same reporting system should make it easy for the accounting department or the management team to quickly review the progress from the billing department. That review as a minimum should provide a process to take a particular date of service range and ensure that every bill has been worked to final conclusion.
This tool for billers and monitoring for management is especially critical in ambulance billing and EMS billing where the entire set of claims for a month payment cycle can be over a long stretch of months. Add in EMS challenges like auto accidents, workers compensation and less timely payments and tracking it needs to be easy and long term.
We all know about the lengthy process of patient payments (whether they were uninsured or co-payments) that make that even more difficult to track, but a good system will be able to tell the difference and eventually track which ones of those patient pay accounts are truly uncollectable, and separate them from collectable accounts and accounts where insurance needs to be worked. Installment plans and other tools also need to be available.
Bottom line is that last 10 the 15% is a lot of work and often requires phone work and a variety of time-consuming steps, but that 10 to 15% of revenue is so important to every organization.
Are you sure you are getting everything you should be in your organization? Can your billing service or billing department assure you of that with detailed reporting? If not that should be a priority to ensure it is.