Press the print button on your browser.
Click here to return to the previous page.
Practice management tips
AMA's Private Sector Advocacy (PSA) Practice Management Center has developed the following practice tips to provide physicians and their staff with educational resources and tools to address private payer and practice management issues.
indicated members only content
Save money with credit card payments—shop around
One of the best ways to ensure receipt of your patients’ payment responsibility is to offer the option of credit and debit card transactions. Learn how to maximize the benefits of accepting credit and debit card payments by contracting with a payment processor that suits your practice’s specific needs and by recognizing how you can save on fees with your current processor. The AMA's Practice Management Center has developed the educational resource, “Shopping for a credit or debit card merchant agreement: Guidelines for physicians,” (PDF, 107KB)
to help you improve your practice’s bottom line.Establishing a cost-based practice fee schedule
The AMA has developed the educational resource “Fee schedule analysis: Using your complete practice cost as a guide”
(PDF, 96KB) to help physicians and their practice staff recognize the need to establish their practice fee schedule based on what it actually costs to provide a service rather than basing their fee schedule on what a third-party payer or other entity wants to pay. This resource includes a 12-step guide to help physician practices create their own unique physician practice fee schedule with an easy-to-complete spreadsheet that will allow physician practices to include additional markup percentages to account for profit, contributions to reserves and future capital expenditures.Helping patients understand their payment responsibilities
Physicians and office staff are encouraged to involve and educate patients about medical treatment decisions, as well as payer payment policies and procedures. Industry trends indicate that both payers and employers are shifting more of the responsibility and cost of health care treatment and payment to the patient. In response to this shift, physicians and office staff need to consider proactively either establishing or revising their practice's payment and collection policies accordingly.
The following educational resources, Helping your patients understand their billing and payment responsibilities
(PDF, 324KB) and Understanding your health insurance policy and payment practices (PDF, 28KB), were developed by the AMA-PSA unit and the Kentucky Medical Association.Mastering the claims management cycle
The first step in the claims management cycle is to improve physician practice viability through efficient contracting. When entering into negotiations with the health plan's representative, physicians need to be well prepared. The more physicians understand about health plans, the better they will be able to decide if a health plan is suitable for their practice. The following educational resources, A guide to working with health plan representatives
(PDF, 146KB) and 15 questions to ask before signing a managed care contract (PDF, 602KB) contains valuable information on managed care contracting. Selecting a clearinghouse to process claims
Physicians and practice staff—are you considering selecting a clearinghouse to handle your practice’s claims process and submission functions? If so, you are encouraged to review the What is a Clearinghouse? (PDF, 33KB) resource developed by the AMA-PSA unit and the Kentucky Medical Association. Designed to educate physicians and practice staff about the clearinghouse function, this resource explains the nuances that relate to the submission and transmission of the physician practice's claim information by an outside clearinghouse.
Defining a medical billing service
Before you consider working with one, it is important to know what a medical billing service is and what they can do for your practice. A medical billing service may help physician practices save time and increase profitability by reducing billing expenses and increasing revenues. A good medical billing service also allows physician practices to concentrate on their patients while increasing the bottom line. To help physicians in this endeavor, the AMA developed the educational resource What is a Medical Billing Service? (PDF, 24KB).
Selecting a billing software vendor for your practice
Purchasing medical billing software for a physician practice can be a daunting task and may result in added costs. To help physicians, the AMA-PSA unit and the Kentucky Medical Association have developed How to Select a Billing Software Vendor for the Physician Practice (PDF, 29KB). The resource provides the physician practice with a proactive approach to determining the specific needs of the practice.
Collecting payment for services rendered
Collection services can play an integral role in helping physician practices improve cash flow by securing payment from hard-to-collect delinquent accounts. To offer physicians guidance in selecting a service, the AMA-PSA unit has developed the resource How to Select a Collection Service (PDF, 30KB).
Appointment scheduling and your bottom line
Something as simple as appointment scheduling can help improve a physician practice’s bottom line. For example, gathering basic patient data at the time the appointment is scheduled allows for the verification of the patient’s health insurance information before a patient’s visit. To help physicians in this endeavor, the AMA, in conjunction with the Kentucky Medical Association, developed the resource Appointment Scheduling to Improve Your Bottom Line (PDF, 513KB).
Taking an active approach to the claims management process
The AMA developed the resource Prepare that Claim (PDF, 1,015KB) to help physician practices review the efficiency of their current internal claims management process. This booklet contains sample forms and policies that can be adapted to fit the specific needs of a physician practice.
Claims submission, processing, adjudication and payment
The AMA developed the educational resource Follow that claim (PDF, 335KB) to provide physicians and their practice staff with an understanding of what happens to a claim once it leaves the practice. A claim is followed as it moves along the claims submission and health processing networks. Understanding this flow will enable physicians to better address the delay, denial and reduced payment tactics used by third-party payers.
Health plan payer's claim edits can effect a physician's bottom line
The AMA developed the flyer The effect a payer's claim edits can have on the repricing and payment of your claim (PDF, 262KB) to raise physician awareness of how a claim edit applied by a payer could affect the physician's bottom line. This flyer highlights how a negotiated fee with a payer for a specific service performed does not necessarily translate into payment of that fee for that service on a claim.
Losing revenue through inappropriate health plan adjustments
The AMA developed the educational resource Is your practice losing revenue through inappropriate health plan adjustments? (PDF, 176KB) to alert physician practices of the need to carefully review health plan explanations of benefits in order to pinpoint and address underpayments based on inappropriate adjustments by the health plan.
Performing an internal billing audit
The AMA, with cooperation from the American Academy of Neurology, developed the educational resource How to Perform a Physician Practice Internal Billing Audit (PDF, 58KB) to help physician practices understand both the need for an internal billing audit and how to perform an internal billing audit to yield improved claims management processes, cash flow, and compliance with applicable laws and regulations.
Preparing for health plan retrospective audits
The AMA, with cooperation from the American Academy of Neurology, created the educational resource How to Prepare for a Health Plan Retrospective Audit (PDF, 582KB) to educate physicians and their office staff about the recoupment efforts of health plans through the retrospective audit process. Physician practices can use this resource to guide them through the retrospective audit process from the initial notification from the health plan to contesting the audit’s findings.
Taking an active approach to the appeals process
The AMA developed the interactive resource “Appeal that claim” (PDF, 1MB) to simplify the claim audit and appeals processes for physicians and their practice staff. This interactive resource can help reduce the administrative burden by delivering a step-by-step course of action to appeal an underpaid, delayed or inappropriately denied claim.
Combating inappropriate health plan claim denials
The AMA developed the educational resource How to Appeal Inappropriate Health Plan Claim Denials (PDF, 131KB) to educate physicians and their office staff about appealing erroneous payment reductions and denials. This resource also includes tips to assist physicians in identifying and appealing inappropriate health plan claim denials.
Establishing an internal collections policy for your practice
An important part of managing the physician practice is addressing outstanding patient balances and taking the necessary steps to receive that balance before sending the patient account to an outside collection agency. The AMA and the Ohio State Medical Association (OSMA) developed the educational resource “Internal collections in the physician practice.” (PDF, 261KB) This resource discusses the importance of collecting from the patient at the time of service and provides useful tips and recommended steps for implementing a collections policy. This resource also includes sample template letters and practice policies to assist in developing physician practice policies.
Improve practice efficiencies and save money
Physician practices can save significant administrative time and expense by electronically performing routine functions, such as verifying patient eligibility and contacting the health insurer about the status of a claim. The AMA has developed the educational resource “Understanding the HIPAA standard transactions: The HIPAA Transactions and Code Set rule” (PDF, 108KB) to help physicians more fully understand the HIPAA electronic standard transactions, the HIPAA Transactions and Code Set rule and how this rule impacts the physician practice. This resource explains how physician practices can prepare themselves for using the electronic standard transactions and how physicians can ensure that health insurers with which they are contracted comply with the HIPAA electronic standard transactions. This resource also provides a survey (PDF, 80KB) that physicians can use to determine the extent to which their practice management software and billing vendors comply with the HIPAA Transaction Code Set rule.
Who owns the data—the physician practice or the billing service?
The AMA, in collaboration with the Healthcare Billing and Management Association (HBMA), has developed the educational resource “Data ownership issues for the physician practice and medical billing service” (PDF, 135KB) to help physicians recognize the questions they should consider addressing prior to contracting with a billing service. This resource addresses topics such as data ownership and issues related to what happens when the relationship between the physician and billing service terminates. Physicians can use this informational resource when considering entering into an agreement with a billing service.
Want to improve your practice’s competitive edge?
In the current health care market, patients are seeking enhanced access to care and top-quality customer service. Offering patients the access and convenience they look for will help keep your practice competitive. Learn more about how you can improve your practice’s offerings by reading the educational resource “10 steps to enhance patient satisfaction in your practice,” (PDF, 69KB) created by the AMA-PMC in collaboration with the Alameda-Contra Costa Medical Association.
Negotiating contracts
Taking command of payer contracts and thoroughly understanding their implications is essential to the success of a physician practice. Protect your practice from inappropriate payer discounts by understanding the implications of contract provisions.
The fourth edition of the AMA's Model Managed Care Contract (PDF, 858KB) offers a reasonable alternative to the one-sided, take-it-or-leave-it contracts physicians typically receive from health plans. The contract includes 10 supplemental discussion pieces on a range of important issues including medical necessity/external review, "all products" provisions, and the restrictions and obligations that can occur after a contract is terminated. In addition to the Model Managed Care Contract, the AMA-PSA educational resource 15 steps to protect your practice from unfair payment practices (PDF, 169KB) offers useful tips.
Protect your practice from inappropriate discounts
Multiple payers could be taking advantage of your lowest contracted payment rate through the use of a rental network preferred provider organization (PPO). The AMA developed the Read your contracts: Is your practice losing revenue through rental network PPOs? (PDF, 138KB) booklet to educate physicians about how to identify and protect their practices from inappropriate discounts.
Automate your practice and reap savings
The movement by physicians, payers and vendors to streamline health care delivery through the adoption and use of information technology solutions strives to create a more efficient claims management revenue process for all involved. By eliminating significant parts of the manual processes in an office's routine, physicians can free their practice staff to perform other revenue-enhancing functions. Read the educational resource Information technology solutions: consider the potential savings (PDF, 158KB) for more tips.
Improving practice efficiencies with electronic claims submissions
The AMA, in collaboration with the Connecticut State Medical Society, developed the educational resource The benefits of electronic claims submission - improve practice efficiencies (PDF, 126KB) to help physicians and their practice staff understand the electronic claim submission process and the many benefits that may be realized by submitting claims electronically to health plan payers. The resource discusses the reduction of claim submission costs and errors, and offers tips on getting started with electronic submission.
Selecting the best EMR/EHR system for your practice
Procuring an electronic medical record (EMR) or electronic health record (EHR) system for your practice can be an intimidating process with the many facets and the multitude of EMR/EHR vendors currently available. How do you select the one that’s best for your practice? The AMA has created the educational resource “15 questions to ask before signing an electronic medical record or electronic health record agreement” (PDF, 105KB) to help you assess your practice’s needs and determine which vendor will best meet those needs.
Connecting with your patients
Online medical consultations, also known as e-visits, present opportunities for growth and increased efficiency in the physician practice.To learn more about this new patient convenience and if it is right for your practice, read the educational resource Online medical consultations: connecting physicians with patients (PDF, 679KB).
Filing a complaint
Physicians and practice staff—alert the AMA of problems you may be experiencing with health plans and payers by visiting www.ama-assn.org/go/clickandcomplain and completing the AMA Health Plan and HIPAA Complaint Forms. These forms gather sophisticated data on the types and severity of administrative “hassles” that the physician practice experiences on a day-to-day basis in the managed care environment.
While the AMA may pursue compliance activities with health plans or payers where a pattern of administrative hassles are shown, the information provided will be used primarily to shape the AMA’s agenda. The AMA does not directly respond to these complaints, as the forms are anonymous. If an AMA member wishes, they may contact the AMA Private Sector Advocacy unit at (800) 262-3211.
Receive payment for your out-of-network services
Physicians’ ability to provide their communities with quality care is dependent on their ability to keep their practices financially viable. It is therefore important that physician practices pursue appropriate and fair payment that is consistent with legal and community standards for legitimate services provided. The AMA-PMC has developed the educational resource “Holding health insurers accountable for out-of-network services” (PDF, 50KB) to help physicians as they seek appropriate payment from health insurers that consider the physician out of network. This resource provides details about what out-of-network physicians might expect when dealing with the health insurer, how these physicians can stay informed about payment laws and issues, and how they can collect fair and accurate payment for their services.
Getting paid what you deserve for out-of-network treatment
The AMA has developed the educational resource Out-of-Network Payment Challenges for the Physician Practice (PDF, 151KB) to provide physicians and their office staff resources to understand the health plan payer’s obligation for payment to out-of-network providers. The resource explains some of the payment challenges that arise when a physician who is considered out-of-network requests payment from a patient and/or health plan.
How to keep your practice competitive
In a shifting environment in which physicians are under pressure to collect, track and report data about the quality of the care they provide, how can small physician practices develop the infrastructure needed to compete in today’s marketplace? An increasing number of physicians are opting to collaborate with other independent—even competing—colleagues to respond to these pressures. In some cases, physician collaboration may allow physicians to jointly contract with health insurance companies and other third-party payers. The AMA-PSA unit has created the booklet, “Competing in the Marketplace: How physicians can improve quality and increase their value in the health care market through medical practice integration,” (PDF, 1MB) to provide guidance on integration issues. Outlining various strategies for physician practice integration—including physician practice mergers, financial integration and clinical integration—this resource can help physician practices stay competitive while complying with antitrust laws.
Implementing HIPAA security requirements in your practice
Physicians who electronically submit claims and conduct other transactions named in the Health Insurance Portability and Accountability Act (HIPAA) must meet a number of requirements. The Centers for Medicare and Medicaid Services (CMS), the federal agency charged with oversight of these requirements, has published a rule that outlines how to meet the HIPAA requirements, which are separate from the commonly discussed HIPAA privacy requirements. The AMA has compiled excerpts from the Handbook for HIPAA Security Implementation, (PDF, 199KB) a 256-AMPress publication, into an interactive online resource to help physicians and their practice staff understand what HIPAA requires with respect to keeping their patients’ medical information secure.
Concerned about health insurers profiling you?
Are you concerned that your patients will no longer have access to your care because health insurers have placed you in their high-cost tiers? The AMA has developed the educational resource Tiered and narrow physician networks (PDF, 206KB) to educate physicians on how health insurers and other payers are profiling physicians by applying analytical software programs to their claims data. This resource explains the episode grouper process that health insurers use to profile physicians for network placement and provides a sampling of tiered and narrow networks that are currently in operation.
What is the process of economic profiling?
An increasing number of health insurers use cost-of-care data from claim databases to profile physicians for network selection. Health insurers post report cards, containing these profile results, on their Web sites in an effort to provide incentive for patients to seek care from the lowest-cost physicians. As an expert consultant to the AMA, J. William Thomas, PhD, has written “Economic profiling of physicians: What is it? How is it done? What are the issues?” (PDF, 117KB) This ten-page paper details the process health insurers use to profile physicians based on cost.
Questions to consider before participating in a pay-for-performance program
The AMA-PSA unit created the “Physician’s guide to evaluating incentive plans” (PDF, 42KB) resource to encourage physicians to evaluate incentive plans for their potential to improve health care quality and their ability to operate in an ethical and fair manner. This resource provides questions and observations that can be useful when looking at common properties of pay for performance and other physician incentive programs.
Evaluating pay-for-performance programs
As pay-for-performance programs become increasingly common, the AMA has created principles and guidelines to outline how the physician community can work to ensure that pay-for-performance programs are positively structured and appropriately applied. The AMA believes pay-for-performance programs must align with the following five principles: (1) ensure quality of care, (2) foster the relationship between patient and physician, (3) offer voluntary physician participation, (4) use accurate data and fair reporting and (5) provide fair and equitable program incentives. Read the AMA resources “AMA Principles for Pay for Performance Programs” (PDF, 62KB) and the “AMA Guidelines for Pay for Performance Programs.” (PDF, 30KB) for more information.
How to prepare for physician profiling
The AMA-PSA unit created the educational resource “Physician profiling: How to prepare your practice” (PDF, 69KB) for physicians to reference when preparing for health insurers’ profiling programs. This resource offers physician practices information on the five steps that encompass the basic elements of the physician profiling process: contract language, program metrics, data, coding and patient education.
Seven-step process to challenge health insurers’ ratings
The AMA-PSA unit created the educational resource “How to challenge your ‘profile’ or placement in a tiered or narrow network” (PDF, 117KB) for physicians to reference when challenging their network placement with health insurers. This resource offers physicians seven steps that address the problems physicians have identified with these types of programs: the use of claims data, inadequate risk adjustment, lack of an appeal mechanism and invalid ratings.
Educating patients about unfair/inaccurate physician profiling practices
While pay for performance (PFP) and other programs that use physician profiling can be a plus when they promote effective, safe health care and adhere to the AMA's Principles and Guidelines for Pay for Performance Programs, patients should be aware that many profiling programs are poorly constructed and often focus primarily on finding ways to save money—not on improving care. The AMA, co-branding with a number of state medical associations and national specialty societies, created a poster (PDF, 118KB) that physicians can post in their offices to raise patient awareness of the many problems inherent in physician profiling programs. AMA members can request a hard copy of the poster.
Understanding the intricacies of Bridges to Excellence
The AMA-PSA unit developed the Bridges to Excellence overview (PDF, 52KB) report to educate physicians about this national pay-for-performance program. Several years ago, large employers and others launched the Bridges to Excellence (BTE) effort to provide incentives for physicians to adopt specific care processes to improve the health outcomes of chronically ill patients and to decrease health care costs. Now, a growing number of health insurers are licensed to offer the BTE programs in their markets. This report provides information on the components of BTE, offers some participating physician observations and summarizes a cost analysis of the BTE diabetes program.
AMA helps physicians evaluate specific health insurers’ physician profiling programs
To help physicians effectively identify and evaluate both problems and positive practices of specific health insurers’ physician profiling programs, the AMA has constructed a series of charts that analyze how components of these programs compare with the AMA’s five Principles for Pay for Performance Programs.
CIGNA Care Designation program (CCD) (PDF, 165KB)
Centers for Medicare & Medicaid Services’ “Physician Quality Reporting Initiative” (PDF, 82KB)
UnitedHealthcare's "Premium Designation" program (PDF, 103KB)
Aetna's "Aexcel" program (PDF, 113KB)
Wellmark's Incedent and Reward Best Practices" program (PDF,101KB)
Each of the private health insurers has reviewed the chart on its program. Physicians can benefit from these analyses in their managed care contracting activities and through AMA and Federation application of these analyses in advocating for change in the design of programs that utilize physician profiling. The AMA anticipates preparing additional charts of major physician profiling programs in the future.
Interacting with the Disease Management industry
Employers, health insurers and the federal government are looking at Disease Management (DM) as a means of harnessing health care costs through the control and prevention of chronic diseases. The types and intensity of DM services can vary. DM can either offer invaluable tools for patients and physicians or be a major obstacle to receiving and providing quality health care. The AMA-PSA unit has created two resources to assist physicians and their practice staff with interacting in today’s DM industry. Disease Management and chronic diseases (PDF, 45KB) provides a basic overview of the DM industry, and Demystifying Disease Management: What physicians need to know for their patients and their practices (PDF, 24KB) focuses on the impact DM may have on the physician practice and offers physicians some strategies for interacting with the DM industry.
Creating a patient registry to manage chronically ill patients’ care
Patient registries assist physicians in identifying and managing the health of patients who have chronic diseases. Increasingly, physician practices are using patient registries to facilitate and improve quality of care and as a means to participate in and/or check on the validity of their results for pay-for-performance programs. The AMA-PSA unit created Optimizing outcomes and pay for performance: Can patient registries help? (PDF, 42KB) to educate physicians on the pros and cons of implementing these registry systems.
Electronic funds transfer agreements
The AMA developed the educational resource “Frequently asked questions regarding electronic funds transfer agreements” (PDF, 29KB) in response to physician concerns regarding electronic funds transfer agreements.
Content provided by: