Radiology Billing, CSI: Managing Individual Payor Contracts

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At NYU Langone Medical Center (NYULMC), New York, New York, even though the radiology department’s billing office adheres to the principle of a cross-trained staff pool, it practices the explicit division of labor: Coders do nothing but code, payment posters post payments, claims processors specialize in making sure exams are coded and processed according to the specifications of each carrier, and customer-service specialists do nothing but answer questions about claims.
imageFelix Okhiria, MPA, MA, CCPO, CMPE, CPC, CHC
Finally, there are the 10 accounts-receivable coordinators who specialize in making sure that no account is delinquent. Felix Okhiria, MPA, MA, CCPO, CMPE, CPC, CHC, director of business services, estimates that the efforts of the accounts-receivable coordinators account for 20% of total revenue.
“We have particular employees responsible for specific carriers. The idea behind that is repetition breeds expertise. The more you work with a particular carrier, the more you know the nuances of what it wants.” —Felix Okhiria, MPA, MA, CCPO, CMPE, CPC, CHC NYU Langone Medical Center, New York, New York
They are, if you will, the crime-scene investigators of NYULMC radiology billing. By making each of his 10 accounts-receivable coordinators responsible for one or more of the 15 payors doing business with NYULMC, Okhiria ensures that each one knows, for example, which carriers bundle transvaginal and pelvic ultrasound exams and which ones treat it as two separate procedures, or whether a carrier recognizes certain abbreviations for left and right or requires the 50 modifier for a bilateral exam. Okhiria is confident that virtually all claims submitted are clean, due to the work of a highly specialized billing staff and the use of a sophisticated, robust edit software program. Nonetheless, 20% of those claims initially are not paid. “The primary function of the accounts-receivable coordinators is to find out why these claims are outstanding, whether by telephone (by calling the insurance company) or by reviewing that claim online, if the insurance company has that capability,” Cassandra Maragh, billing manager, explains. Once the accounts-receivable coordinator finds out the root cause, it is his or her responsibility to resolve the issue. If the claim is denied for lacking authorization—unlikely because NYULMC does not do an exam without authorization—then the coordinator will provide the number and the carrier’s representative will probably reprocess the claim over the phone. If the procedure was miscoded, the coordinator might take it to coding to be recoded and then resubmit the bill. “That is the coordinator’s primary function,” Maragh adds. Dual Strategies Okhiria’s billing department is responsible for global billing for all outpatient imaging procedures and for billing for the professional component of inpatient radiology at NYULMC. He deals with accounts-receivable management in two ways. “Having employees work with specific payors is one of those,” he says. “The second is targeted: Sometimes we target a specific payor.” On a monthly basis, Okhiria and Maragh review data for each payor to assess whether accounts receivable are trending up or down (or remaining stable). If a particular payor is not at the expected level, then the accounts-receivable coordinators are asked to investigate and to provide a report breaking down the outstanding receivables into categories. These can include problems with preauthorization, bundling, and multiple procedures (which primarily affect inpatient emergency-department billing). On a given day, a patient with a broken bone, for instance, might have multiple radiographic exams, and there are different modifiers for the same exam done on the same day by the same radiologist (modifier 76) versus the same exam done on the same day by different radiologists (modifier 77). “I will take the result of that targeting, pick up the phone, call the vice president of the carrier, and say, ‘We have ‘x’ amount in receivables from you. Here are the specifics by patient, by procedure, by exam, and by CPT® code.’ Usually, we are able to get results very quickly,” Okhiria says. Billing is a subject that he is passionate about, and he punctuates his conversation with anecdotes collected over 11 years with the institution’s billing department. He clearly takes personally every delinquent account. “When we have denials, it is not of malicious intent,” Okhiria says. “I doubt that any carrier sits down and says, ‘I don’t want to pay this.’ Most of this is due to archaic systems or inefficiencies, so that when you bring this to their attention, for the most part, they are open to resolving it.” On the Hunt Okhiria shares a story about the time that he took $300,000 in denials for lack of preauthorization to a payor in lower Manhattan, armed with preauthorization numbers for each of those denials. The carrier’s executive brought up three screens, and one had all of the authorizations that were submitted. Another showed all of the preauthorization numbers that had been issued—but the two systems were not interfaced. “Needless to say, they cut a check for us within a week because we were able to offer irrevocable proof, and this happens all the time,” Okhiria notes. “Relationship building really matters. A huge portion of my effectiveness in being able to [resolve problems at the carrier level] is knowing whom to call.” His accounts-receivable coordinators also know whom to call, he says. “When you work with certain employees, you get to know them,” Okhiria emphasizes. “You can talk to them; you can call them up and say, ‘I think there’s an error here.’ It is very advantageous. Relationship building runs the gamut here. It dominates this process that we do.” Okhiria concludes with some hypothetical arithmetic. “If our revenue is—and I am not saying it is—$50 million, and 80% is paid, that’s $40 million,” he posits. “Twenty percent is $10 million, so you tell me: Is it worth $10 million? Absolutely: that, right there, is the impact of the 10 people who work as accounts-receivable coordinators.” Cheryl Proval is editorial director of Medical Imaging Review and editor of Radiology Business Journal.