Return on Patient Investment

Written by on December 31, 2013 in Insight - No comments

You invest time and resources into continuing medical education and technology improvements throughout your office to provide the highest level of care possible. You spend money on marketing efforts to attract patients to your practice to be able to provide this care. While the patient is in your office you are in control of their satisfaction. Your bedside manner and medical acumen determine whether the patient is satisfied with the care they receive. However, after the patient leaves your office, their satisfaction is dependent on a number of factors, including the many aspects of how their financial obligations for the visit are handled.

In today’s volatile healthcare marketplace, it is imperative to understand the importance of a streamlined revenue cycle, and how keeping patients coming back can be just as much about providing excellent customer service as it can be about providing quality medical care.

Expectations & Communication

Your communication, or the lack thereof, sets the stage for your patient’s expectations in terms of the revenue cycle.  As soon as the patient makes an appointment, your staff should make the patient aware of the payment policy around copays, deductibles and coinsurance.  When the patient presents for the appointment, assert this by having policies posted at check-in and check-out.  Finally, follow through and request said monies due. This is easier said than done, but it is easier to collect from the patient when your policies are made clear from the beginning.

The patient’s liability is largely dependent upon their coverage through the individual insurance carriers.  It is in the best interest of the practice to verify coverage, pre-authorize services, and estimate the portion of the visit that is the patient’s responsibility.  Just as important as determining this information, however, is clearly communicating your findings, and the resulting liability, with the patient ahead of time. Nothing upsets a patient more than receiving a bill for services that they thought were completely covered.

Additionally, if you outsource your billing functions, be sure to give the patient the contact information and let them know from the beginning that your billing functions are handled by a third party.


The revenue cycle itself starts with you documenting the services provided to the patient.  It is extremely important to be clear and thorough in every aspect of your documentation. If you are deficient in any way, it will compromise your ability to accurately code the chart, which will have a negative impact on the revenue cycle.  Not to mention the potential impact on patient care, both within the same practice and with outside practices through referrals.  Proper documentation is imperative for providing good customer service to your patients.  Don’t compromise the entire process in this crucial, but often cumbersome, step.


Regardless of whether you code your own charts or have an outside agency do it for you, coding drives the insurance process and determines if a claim is paid, how much is paid, what is the copay, is there a deductible, etc.  Something as simple as a modifier or preventative vs. medical diagnosis can compromise payment.  With ICD-10 being effective in October 2014, this piece will become even more cumbersome for the provider and confusing for the patient.  The easiest way to upset a patient is to assign an inappropriate code such that they receive an unnecessary statement with a resulting call to you and/or the insurance carrier.  Most patients are not going to understand why certain codes were or were not used and the insurance carrier is only going to refer them back to you anyway.  You need to get it right the first time.


You have done your part to collect patient copays and deductibles, appropriately document and code the visit, now what?  If the claim isn’t submitted in a timely manner, not only could that result in the patient being unhappy but it could also result in your not being paid at all.  Claims have the possibility of getting stuck in various parts of the process: charges not entered, claim errors delaying submission, clearinghouse edits, payer kick outs, etc..  You must have personnel continuously monitoring the process to make sure that everything is being promptly submitted and  that claims are not falling  through the cracks.

In addition to the initial claim, there are also secondary and tertiary claims to take into account.  Regardless of whether these claims are crossed-over from Medicare or automatically generated from your system, you still have to be proactive monitoring these claims.  Generally speaking, collecting the last 20% of the amount due requires up to 80% of the work.  If a patient is waiting on an Explanation of Benefits (EOB) or statement to submit expenses for reimbursement or file their taxes, do you want to be the piece of the puzzle that is holding up the process?  I didn’t think so.

Payments & Denials

Payment arrives!  You’re done, right?  Nope.

You must have edits within your practice management system that verify that the payment you received is accurate based upon the managed care contract that you have with the various carriers.  Not receiving the accurate payment could mean a disproportionate amount due from the patient in terms of the coinsurance and deductibles. This is one area where spending the necessary time setting up the process on the front end can pay huge dividends on the back end.

Should you be lucky enough to receive a denial, that shouldn’t just sit around either.  A lot of providers put the burden on the patient to research a denial that isn’t related to the actual medical care.  In this day of eligibility verification and real time edits, your staff can do much more work to resolve a denial without having to involve (and possibility infuriate) the patient. Patients generally do not want to accept responsibility for any portion of the billing process. It is best to avoid having them do the legwork for issues that could have been handled by your staff or, better still, prevented in the first place.


At the end of the day, should your patient receive a statement with a denial or an amount due that they must take action on, the statement must be clear TO THEM, not just to your office staff!  If you took the time and spent the money to send the patient a statement, make sure that they don’t have to call your office to discuss the statement.  In order for this to happen, the statement will need to have the following clearly listed:

  • Full description of the visit and what they are being charged for.
  • Detail of all insurance payments and denials. If there are denials listed, make sure that they are written in clear language that the patient will understand.
  • Breakdown of everything that is the patient’s responsibility. Simply listing the total balance on the account is not enough.
  • Make sure that remit to and contact instructions are clearly marked. The easier you make it for the patient to handle this on their own, the more likely they will be able to do so.

Contact & Follow Up

Of course, your staff should be easily reachable and thoroughly educated in the revenue cycle process. In addition, they need to provide exemplary customer service and be eager to assist any patients who need help.  The last thing a patient wants is to be told to call the insurance carrier or to be pushed off to someone else for assistance.  If for any reason you do have to tell the patient that you will research the issue, you MUST circle back around and follow up with the patient.

If you utilize a billing service make sure that you are clear with them regarding how your patients should be treated.  Let them know that they are an extension of your practice and that you expect consistent treatment throughout the entire patient experience.

Patient satisfaction is key in a growing medical practice.  It’s common knowledge that it costs less to retain established patients than it does to attract new ones.  That being said, it is easy to lose focus on the full patient experience while you are trying to provide the best care possible and run a business at the same time.  The key is having the proper workflow and policies in place, and making sure that everyone on your staff understands your purpose and is on the same page. With a streamlined, complete, and accurate revenue cycle you will not only see an increase in patient satisfaction, but you will also see a nice increase in reimbursements.

Win / Win!

By Michelle Durner
Applied Medical Systems, Inc.

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