Ever get that feeling that there should be more charges in the billing system?  How many times have you or someone else said something like “we did 3000 samples last month, but we only see 2500 that got billed”?  Are salespeople complaining that all their samples aren’t in there?  Can you tell if they are just complaining, whether the referral source didn’t send as many as they think or claim (which we all know happens). What if there were more samples transmitting and instead of someone billing them. Are just going “poof”?

Where can revenue be lost?

Tons of places. Most people in the laboratory world are familiar with the concept that not all claims get paid. Everyone is used to this concept if you have been in the business for any period. Hence, you know that there is some loss in that billing process where payers don’t pay. And at least you can see where the loss resides by looking at denials or unpaid samples sitting in AR (or you should be able to). If you want to dig, you can determine which payers are the worst or what particular problems you can investigate that make up the most significant number of written-off claims or unpaid claims.

But What if there was no claim? How would you know there was something wrong in the revenue cycle? You can quantify what percent of your shares are written off or sitting unpaid in AR, and you can even compare this to other labs (this is feasible, although few labs do this). What if you did not create a claim for a particular sample? No one would ever follow up on it and try and get it paid. It would never be written off as such. Further, it would never be sitting unpaid in accounts receivable. Plus, it would disappear into the void, never to be heard from again. How is this possible?

Remember the revenue funnel

Think of your revenue funnel where they can fall out at any stage:

  1. Samples accessioned
  2. Samples billed
  3. Samples paid

There is a step that people don’t realize is missing from the above.  In fact, there are actually several steps potentially depending on your RCM workflow.  Where does loss come from where samples just disappear?  Did you billing department or company make a mistake or was it something else?

Let’s walk through your operational steps in the RCM process. We’ll also look at where there can be problems that result in lost samples.

Note the RCM Workflow Gaps

Samples come into the lab. Then they get accessioned. Let’s stop here for a second. There will be some samples that never get accessioned for various reasons. Your lab may keep a log of these outside the LIS. This log is incorporated into the charge reconciliation (and we recommend you do this). Why? So that you can get a complete view of how many samples are transmitting from where. You also want to look at any problems that result in an inability to accession the selection concentrated in particular referral sources. For this article, we will assume the volume you did not accession is low and manageable in your operations.

After accessioning the test(s) are run, then you can see the results. Also, the status in the LIS/LIMS is changed to typically either “Resulted” or “Ready to the bill.” Samples can get stuck in a “Pending” status or similar and never be resulted, so one part of the reconciliation should be to see how many get stuck in this stage. Many workflows for labs leave all samples as “Resulted” or “Ready” because there is no automatic flag to switch it over even if there is an interface or someone manually logs into the LIS to bill the samples. The reality is that it doesn’t matter. Samples can be labeled in the LIMS “Pending,” “Resulted,” or even “Billed” and still not be billed. If you are doing the recon, you will find any of these and bill them, regardless of their status in your lab system.

Revisit manual claims

If someone is entering claims manually from the LIS into the billing system (this is common), someone needs to go through the list of accessions in some status like resulted. Billers can manually going down the list and miss one or even some accessions and not enter them since it is hard to track. Even if there is a flag to switch to “billed,” they can lose track and flip the wrong ones. We have seen billers sometimes even miss a day of accessions entirely.
What gets confusing is that many LIS automatically flip something to “Billed” under some conditions. For instance, once the data is sent via the interface. However, “sent to billing” is not the same as “received by billing,” much less “entered by billing,” or actually “billed.” When an interface is present, there can be many problems. The LIS never sends the record for the accession. Also, the record transmits, but it never gets through the interface engine to billing.

Determine the issues

It could be that there was some problem with the file or that someone didn’t create a rule to handle that situation, so it disappeared. If no one is checking the interface engine logs, they will get stuck. Additionally, they can transmit from the interface engine to the billing system without input. And, of course, they may not have billed status. We have even seen complex scenarios where there was a weird intermittent problem where some part of the record was missing. For example, the Insurance ID field.

Thus, even though insurance had been loaded, it was dumped into Self Pay. Also, it was billed to the patient with little success. Other times because of the poor match-up in master data files, the insurance didn’t match anything correctly in the billing system. It got billed to the wrong payer, who then denied it for ineligibility.

Look At the Big Picture

The average across all labs is close to 5% of accessions that disappeared and did not bill. These are often accessions that require billing, but they are often also samples where there was some problem that drove the inability to enter or bill. We have done reconciliations that found thousands of samples in a single year that they did not enter the billing system. If you are down at 1%, you are exceptional. On the other hand, you just haven’t found the problem yet. We just performed one that found 1,850 accessions missing out of just 19,000, nearly 10%. I wish I could say this was extraordinary, but it is not.

Understand: What’s a Lab to Do?

Charge reconciliation. Daily, monthly, and rolling 12 months. Identify anything that was accessioned but not billed and track it down and get it out. Daily recon requires an excel/CSV file sent daily to reconcile what it displays in the interface. That helps with one part but still won’t catch what it did not send. Anything that remains in unresulted status for too long will show up and will require investigation. If it shows up and does not receive a flag for billing, you can still bill.

Take Baby Steps First

Full-blown reconciliation takes a significant amount of time to set up and get right, but when you do, it is gratifying – like free money. Export an accession list with the status from your LIS and cross-reference it to see which accessions are not in your billing system, and run some pivot tables. Of course, the foundational and critical requirement is that your billing system needs to load and report accession. You will quickly start finding unbilled and unentered accessions.

Contact us to find out how many claims are missing that could be submitted.  Found claims is found money.

Learn More About Apache Health

Apache formerly ran a large medical billing company that a private equity group acquired in a rollup. Also, Apache’s predictive analytics will benchmark billing performance and project exactly how much more revenue you should earn from your existing volume of patients. Using many factors and a blend of artificial intelligence and specialty-specific benchmarks, the model projects whether changing the billing process would improve collections for your particular mix of procedures and payers. In addition, Apache Health can help you evaluate whether to outsource the billing, determine which billing company to select to maximize performance, or track in-house billing performance improvement over time. For more information contact: Sean McSweeney.

Apache Health




For more information from Apachehealth.com. Please subscribe to our blog. Enter the details below and click on "Subscribe" button