The financial health of the physical therapy clinic of course depends on the strength of the billing process, which in turn hinges on the front end process (taking place at the front desk). The more that is done at the front end, the less there is to worry about at the backend. Benefits verification and efficient onboarding at the time of check in does save a lot of trouble when billing the payer. What will help is to forecast any looming troubles ahead of time like running out of payer or Rx authorizations. That will help ensure that there are no unexpected interruptions to delivering care.
Billing is the quarterback that brings everything together. There are some â€œbest practicesâ€ that when followed should maintain a healthy pace of collections and cash flow. When using EMR and practice management software, the charges should be baked into the actual documentation templates with modifiers preloaded as per preset billing rules and ICD pointers automatically applied. Therapists would review units and minutes before submitting charges. Then it is over to billing.
The Billing Process
The first step in billing is charge review where all charges are scanned for any item that could potentially cause a rejection or denial. There are some boxes that we could check off. Missing authorizations. Missing eval codes. Missing diagnosis pointers. Unsigned notes. Charges without corresponding appointments. Units per visit that are out of line with the norm. Time based codes that break the 8 minute rule. Among others. The goal is to maximize the First Pass Resolution Rate (FPRR) or the Clean Claims Rate, the share of a practice’s claims that get paid upon first submission.
Billers can either fix the problem(s) themselves or send them back to the provider/therapist for making necessary corrections. This is followed by creation of claims batches. With practice management/billing software, claim scrubbing can be completely automated with additional manual overrides as necessary. Once the claims are all â€œgreen,â€ they can be sent to the clearing house. Collections follow up needs to be part of the overall workflow so that collections follow up can happen as per payer-specific schedules. Again, your Practice Management/Billing software should be able to help. Once the EOBs/ERAs are received, they are posted, ideally automatically, with detailed intelligence behind what is happening under the hood and the flexibility for the biller to override it as and when needed. Remaining charges could be written off or sent to a secondary payer or transferred to patient responsibility. Amounts collected at the front desk could be automatically allocated. With a selection of reports and dashboards, it would be possible to stay on top of the process, making it predictable with no unexpected surprises.
The software would work off the billing pyramid. At the base of the pyramid is every CPT code in the system: both time-based codes and non-time based codes, essentially this is the master fee list. Then there are the payer specific fee classes on top, the codes and modifiers that are allowed for a particular payer class along with gross and contract charge amounts. Payer specific rules are at the top of the pyramid, for example does the payer require authorizations or prescriptions, do they use the 8 minute rule or not.
Striking a Balance
There is always potential for some misalignment between clinic owners who would like to max out on coding and billing vs. therapists/clinicians who may routinely under code. As long as the final charges reflect what is there is there in fully defensible documentation toward achieving plan of care goals, this should constitute healthy tension, part of the balance, and everything should be hunky dory!
It may be noted that the government had stepped up efforts to target physical therapy billing issues, especially in the case of Medicare and Medicaid billing, back in 2019 and 2020. There is evidence that these efforts are continuing this year. Areas to stay alert on would include duration and scheduling of services, rounding off times in the case of time based codes, extent of alignment of services provided with plan of care goals, use of licensed vs. unlicensed therapists, and so on. Again, it is all about billing to the maximum permissible level without breaking the rules.
Your practice management software should be a critical partner in this endeavor so that you can stay ahead of the curve as a billing ninja, keeping things in balance.