You are losing up to ten percent of your collections if payer underpayments are not being aggressively pursued by your outsourced medical billing company. It is simply a minimum requirement of being in business that medical billing services compare your payments to the amounts your payers have agreed to pay you.

Medical billing services have a number of basic steps they should incorporate into their billing process. These steps should include using a claims scrubber, use of no-response calls, posting zero pays, pursuing underpayments, and using likelihood of payment scores for patient collections.

Today’s focus will be on pursuing underpayments. The first step of this pursuit is comparing a practice’s Explanation of Benefits from the payers to the amounts the payers have agreed to pay for each procedure. Many billing processes assume the payment posters will catch these underpayments; this is a bad assumption. The billing process must have an automated comparison process.

The reason that comparison to allowables must be automated is because of the clever and systematic manner in which payers typically underpay claims. These underpayment patterns can be difficult to spot, but one of the advantages a Medical Insurance Billing Service has is that it sees payment information and patterns across many clients for many payers. This allows medical claims billing services that regularly and systematically compare payments to contractual allowables to spot patterns that a single practice might miss.

A pattern that is often seen by billing companies is one where a payer will underpay the same codes across multiple providers by the same dollar amount in month one. Then in month two, the payer will resume paying the code correctly and will begin to underpay a different code (or codes) across multiple clients.

Although the amount of the underpayments may be small ($5 to $15), the totals can be quite large: upwards of a 10 percent net reduction in the payments the payer sends the practice. Despite the magnitude of the total, the constant hopping from CPT to CPT for underpayments and the relatively small amount of the underpayment on any individual claim makes the loss of revenue hard to spot - let alone pursue.

Needless to say, it would be difficult for a payment poster to remember enough about the allowed amounts across a practice’s tens of payers and dozens of CPTs to spot the underpayment strategy described above. This is why it is critical that automated comparisons be performed by your medical billing service.

Identifying and pursuing underpayments can yield big returns for a medical practice (the average practice can increase collections by 7%). Therefore, it is imperative that your billing service is aggressively pursuing these underpayments on your behalf.

Identifying the underpayments is the first step of the journey. Dogged pursuit of the underpaid amounts is what actually drives up your practice’s revenue. This pursuit needs to go down to even small underpayments because once a payer sees that the small underpayments are being pursued they typically taper off and contractual payments resume at the appropriate level. Much like a small child, the insurance companies are trying to see what the can get away with.

Copyright 2008 by Carl Mays II