Five Steps for Effective Financial Management

The financial management of a retina practice involves all employees, not just the billing manager. From the pre-visit phone call to the final reporting, everyone plays a part in the process, and every touchpoint of a practice will affect the bottom line. A financially strong retina practice must:

• Establish a strong pre-visit financial clearance process
• Maintain effective inventory management
• Create and maintain a library of clinical guidelines
• Ensure the doctors and scribes provide adequate documentation
• Monitor performance through effective reporting

In this article, we walk you through each of these five steps to help you establish control of your finances and ensure your practice maintains a healthy financial future.

PRE-VISIT PROCESS

The first step toward financial security takes place before a patient even darkens your doorway. Pre-visit financial clearance for new patients starts in your call center. Although it is critical that all health care practices gather accurate data, the stakes are particularly high in a retina practice that uses high-cost medications on a regular basis. Your call center staff should obtain accurate demographic and insurance information by obtaining and verifying it in real-time (while the patient is still on the phone). This will help your staff identify patients who have Medicare but are enrolled in a Medicare Advantage plan that requires referrals and/or authorizations, giving you time to plan the patient’s care accordingly. Some practices may have a system in place that can do this within the software, while other practices may need to research ancillary patient engagement platforms to streamline this process.

For established patients, your billing department should be reviewing each patient’s care plan at least 2 weeks prior to the appointment to ensure the practice obtains all the necessary authorizations before the date of appointment. If your practice does not have a prior authorization system, you can consider using Samacare, a free web-based software designed to streamline the process for retina providers. This platform allows you to submit, track, and manage prior authorizations. As an added bonus, using a system like this can create visibility for management into the burden of the prior authorization process.

In addition to the upfront paperwork, you should consider collecting any copayments or coinsurance before the clinician sees the patient. Many retina medications are costly, and the 20% coinsurance many patients are responsible for can be a heavy burden; if not collected appropriately, these copays/coinsurance bills could lead to loss for the practice. Copayments should be collected up front or patients should be enrolled in one of many patient assistance programs. Good Days (www.mygooddays.org), a national nonprofit that provides patient assistance and financial resources, may be able to help Medicare and Medicare Advantage patients struggling with the financial burden of treatments. Drug company assistance programs may also be a generous option for those who qualify.

Running a busy retina practice can make it challenging to carve out time to research and recommend these financial programs to patients struggling with their copays; however, this is a crucial patient service that is also a wise financial management decision.

INVENTORY MANAGEMENT

Every drug in your practice needs to be accounted for every day. Whether you use a paper log or an electronic system, you must ensure that you can account for each billable drug, each specialty pharmacy medication, and each sample used. Every time someone in the practice uses a drug, they should enter that as a charge in your practice management system. Anything short of 100% billing accuracy on retina injections should be unacceptable in a practice. Billing inaccuracies, such as incorrect units on J codes, not billing injections administered to a patient, or incorrect bilateral injection billing format, can all result in a need to submit corrected claims and possible appeals. This can delay payment for weeks.

LIBRARY OF CLINICAL GUIDELINES

Knowledge of your payers and their individual guidelines will prevent treatment plan changes and authorization denials; it will also help you file clean claims to the payer. To help all staff stay up to date on each payer’s requirements, create a set of guidelines within your own practice.

• Create a grid of step therapy requirements and include each medication, appropriate diagnosis, and need for step therapy for all medications used in your practice.
• Create a grid of bilateral billing rules per payer. Medicare and some payers prefer bilateral treatments billed as one line with a -50 modifier, while others may want two lines with an -RT and -LT modifier.
• Know your J codes, units, and national drug codes (NDCs). The American Academy of Ophthalmic Executives (AAOE) maintains a Table of Common Retina Drugs, which is one of many great reference tools.
• Know that the Part B drug costs are updated quarterly and ensure your charge master is set accordingly. You can obtain quarterly pricing in the 2021 ASP Drug Pricing Files at www.CMS.gov.
• Program your NDCs correctly in your practice management system. Ensure you have loaded an 11-digit format so that claims are properly processed by your insurance carriers.
• Create and maintain practice management claims edit scrubs to ensure your practice is adherent to these guidelines and formats.
  • You can program in the FDA-covered diagnoses per medication to ensure you do not submit a charge for a noncovered diagnosis.
  • You can program the required billing units on the J codes.
  • You can program the bilateral billing rules per payer. For example, a Medicare bilateral injection must be billed as one unit with a -50 bilateral modifier and the J code medication with double the units.
  • You can program the authorization requirements to ensure you do not release a claim without attaching the authorization.

DOCUMENT, DOCUMENT, DOCUMENT

Work with physicians and scribes to ensure that medical necessity for a specific drug is clearly conveyed in the medical record. Also, ensure that step therapy is documented consistently. This will allow your authorization team to obtain prior authorizations in a timely manner so that your physicians can provide the care they feel is best for each patient. In addition, ensure that the injection procedure is documented thoroughly. Medicare audits of retina injections and visits with -25 modifiers (a significant, separately identifiable evaluation and management service on the same day as a minor surgery) are commonplace. If your records are not clear and complete, you may suffer recoupment of payments upon audit. The AAOE has audit checklists that can assist you in reviewing your own records to be ready for the inevitable audits.

Your revenue cycle team is only as strong as the documentation you provide to them. The AAOE has many resources to help. Our go-to reference for all things documentation is the AAOE’s Ultimate Documentation Compliance Training for Scribes and Technicians.

REPORTING

Last, but certainly not least, is management reporting. Review all charges, payments, and adjustment reports on a daily basis. On a monthly basis, review your outstanding J code accounts receivable to ensure that you have received appropriate reimbursement for all medications.

Review claim rejections and denials with the entire team to ensure you get to the root cause of any denials or underpayments. Once you know what went wrong, you can make the appropriate changes so that it does not happen again.

Remember to compare the drug revenue from your practice management system to the cost of medications in your financial system. You should be netting approximately 6% on all Part B medications. If you are not, find out why!

CLINICAL IMPLICATIONS

These five steps, when followed properly, can help everyone within your practice work together to capture every dollar the practice deserves. Having the tools in the billing department is not enough. You must regularly provide feedback to your call center, front desk, technicians, scribes, and doctors. Not only will this provide fair reimbursement, it will improve the entire patient care experience.

Claim denials and post-visit statement billing can be distressing to patients who are undergoing regular treatment. We want then to feel confident, not only in the medical care they receive in the practice, but in the entire patient care experience.