Successful pain management practices have implemented processes and procedures that focus on customer service, physician and staff efficiency, and risk reduction which result in optimizing the revenue cycle. The goal is to ensure that all revenue cycle tasks are performed by the right number of people at the right time with the right tools to collect timely and optimal revenue. The revenue cycle, or the process of getting paid, begins with the patient entering a pain management practice and ends with collection of all collectable dollars associated with the services provided to that patient. Every employee and provider in the practice, from the person who answers phones to the pain management professional, has an important role to play in the revenue cycle.
Revenue cycle processes can be divided into two types as shown in Table 7-1 —the processes performed on the front-end and the processes performed on the back-end. Front-end processes are those that typically are performed with patient involvement, whereas back-end processes are performed without the patient’s involvement or presence. The accuracy of patient information and timely completion of front-end processes drives the success of the back-end processes to ultimately achieve revenue optimization.
| Front-End Processes | Back-End Processes |
|---|---|
| Appointment scheduling and pre-registration | Claim/statement production |
| Insurance verification and referral management | Payment processing and analysis |
| Check-in | Denials management |
| Patient encounter | Accounts receivable follow-up |
| Test/procedure coordination | |
| Check-out |
Front-End Processes
Front-end processes in the revenue cycle include appointment scheduling and preregistration, insurance verification and referral management, check-in, the patient encounter (where coding and documentation occur), test/procedure coordination, and check-out.
Appointment Scheduling
Appointment scheduling is typically the practice’s first encounter with the patient and is one of the most critical steps in the revenue cycle. Future third-party billings and collections efforts depend on the quality of the data obtained at this time. Therefore, it is imperative that accurate and complete patient demographic and insurance information be obtained. The appointment scheduling process includes, but may not be limited to, the following tasks:
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Obtain all patient demographic and referring provider information and enter into the practice management information system (PMIS); this is called preregistration
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Re-register all established patients (e.g., verify or update previously obtained demographic and insurance information)
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Make the appointment, hopefully within patient’s desired time frame
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Inform the patient of practice’s financial policies including collection of co-payment at the point of service (POS),
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Refer the patient to the practice’s website (if one is available) to download a map, health history form, other patient education materials
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Coordinate or make a reminder phone call to the patient about the appointment and financial policies
Successful practices obtain patient demographic information directly from the patient, rather than from the referring physician’s office, to ensure accuracy. Practices that are business savvy offer on their website the ability to make an appointment and provide preregistration demographic and insurance information.
Insurance Verification
Insurance verification and referral management can be a separate process, depending on the size of the pain management practice, or it can be performed at the time of appointment scheduling. Practices obtain required managed care referrals and verify the patient’s insurance eligibility and benefits prior to all new patient appointments to ensure appropriate collections on the back-end. Successful practices will re-verify insurance benefits on all established patients not in a postoperative global period. All too often a practice finds that a patient, new or established, does not have the insurance coverage he or she claims to have and the practice ultimately is not paid for rendered services.
Validation of insurance eligibility and benefits as well as obtainment of referrals for pain management services may be done electronically through on-line capabilities with many payors. It is not always necessary to have this task performed via telephone call requiring staff time. The on-line capabilities come in various formats, such as accessing information directly from a payor’s on-line database or through the PMIS vendor who might perform “batch” (for a group of patients) or “on demand” (for an individual patient) eligibility and benefits verification for the practice.
In summary, the goal of the first two steps in the revenue cycle is to gather and verify patient demographic and insurance information prior to the appointment to provide an optimal opportunity to assess the financial risk, verify insurance eligibility, and obtain proper referrals to ensure appropriate revenue collection when the service is provided.
Check-In
The receptionist plays an important role in the revenue cycle process by validating the patient’s identity and the previously obtained insurance information, as well as collecting any mandatory copayment. Tasks required at the check-in phase of the revenue cycle include, but are not limited to:
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Marking the patient as “arrived” in the PMIS so the system “looks for,” or reconciles, a corresponding charge for the service provided
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Scanning the patient’s insurance card into the PMIS (or photocopying for the paper chart)
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Validating the patient’s identity by comparing the name on the insurance card to the name on a government-issued photo identification card to the patient’s actual identity
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Obtaining required signatures on practice forms or electronic documents (e.g., consent to treat, information release) and communicating the projected patient financial responsibility for the service
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Collecting any insurance company mandated co-payment, entering this action in the PMIS, and providing a system-generated receipt to the patient
It is imperative that co-payments be collected at the point-of-service because this is the point at which the patient’s motivation to pay is greatest and the cost of collections is lowest.
Patient Encounter
The pain management provider renders a service in the office (e.g., evaluation and management code, radiology code) or a procedural service (e.g., injection code, surgery code) and is responsible for documenting and coding the service so accurate billing can occur. Coding for, and documentation of, services performed is best performed by the rendering provider because these are critical components of the revenue cycle. Coding is typically performed on a paper charge ticket, also called an encounter form, or may be done electronically through the PMIS.
CPT Codes
Current procedural terminology (CPT) is a set of codes, descriptions, and guidelines intended to describe procedures and services performed by physicians and other health care providers. Each procedure or service is identified with a five-digit code. The CPT manual is updated annually by the American Medical Association (AMA) and the pain management professional specialty societies contribute to CPT code development and maintenance. There are extensive service and procedure coding requirements published in the CPT manual. Providers are responsible for knowing how to accurately report, and document, CPT codes for the services rendered.
There are three categories of CPT codes. Category I CPT codes describe a procedure or service identified with a five-digit numeric CPT code and descriptor nomenclature; these are considered the “usual” CPT codes and are widely accepted by third party payors.
Category II codes, five-digit codes with four numbers and ending with the letter “F”, are intended to facilitate data collection on positive health outcomes and quality patient care. Category III codes, five-digit codes with four numbers but ending with the letter “T”, facilitate data collection on and assessment of, new services and procedures and are used to report procedures that do not have a Category I code. Payors require a valid Category I and/or Category III code(s) for payment consideration. The various types of CPT codes are listed in Table 7-2 with a notation of the application to the pain management specialty.
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