Private practice lays the responsibility for operations and financial management of the practice into the hands of physicians—a topic that too often goes unaddressed in medical school and residency training.
The AMA has developed a wealth of information to help new and established physicians understand, keep current on and confidently navigate the complexities and frequent changes in getting paid, including advice on private practice revenue cycle management, the Medicare Quality Payment Program, and medical coding and billing.
Many of these resources are part of AMA STEPS Forward®, a program that offers real-world solutions to common challenges in health care today. Through a variety of innovative, physician-developed resources designed to help prevent physician burnout, optimize workflows, improve well-being, and enhance patient care.
STEPS Forward is part of the AMA Ed Hub™, an online platform that consolidates all the high-quality CME, maintenance of certification, and educational content you need—in one place—with activities relevant to you, automated credit tracking and reporting for some states and specialty boards.
These and other AMA resources tackle the revenue side of medicine in depth, but three major domains warrant immediate and sustained attention. They are: navigating the insurance maze, getting coding correct and knowing how to collect payment.
The AMA Independent Practice Accelerator Workshop, taking place Sept. 11–12 at the AMA headquarters in Chicago, is designed to give physicians the essential knowledge, practical skills and confidence to launch or strengthen an independent practice in a concentrated, high-impact format. The deadline for registration is Aug. 27. Learn more and register now.
Focus on insurance and prior auth
The STEPS Forward toolkit “Revenue Cycle Management: Streamline and Automate Your Practice's Revenue Cycle” highlights the importance of verifying insurance eligibility electronically before every patient appointment.
“Unfortunately, the following scenario has probably happened in your practice: Your team learns that a patient was not covered by a health plan or has an out-of-network plan after a service has already been provided. You and your patient now both face the unwelcome challenge of addressing a surprise bill that is potentially higher than the patient can afford,” the toolkit says.
This pain can be avoided simply by verifying patient eligibility before all appointments—something that can be done electronically.
“A general health plan coverage inquiry will return information about a patient's medical, chiropractic, dental, hospital, emergency services, pharmacy, physician office, vision, mental health and urgent care benefits,” it says. "In addition to indicating the patient's coverage, the electronic eligibility response also provides information regarding any copays, coinsurance or patient-specific remaining deductibles.”
Meanwhile, the "Private Practice Playbook" tackles another burden on private practice physicians: prior authorization. Besides defining foundational terms and concepts that apply to private practice, it provides guidance on how to streamline the prior-authorization process.
“When it is used, prior authorization should follow a standardized, automated process (often called electronic prior authorization, or ePA) to minimize the burden placed upon both physicians and health plans. If ePA is not available for you, ask your EHR vendor when that capability will be added to the EHR workflow,” it says.
Avoid being tripped up on coding
“Fraud and abuse” is the federal government’s go-to language about Medicare and Medicaid billing disputes. It, along with reports of sky-high penalties, sends powerful signals of how serious correct coding should be taken at every practice.
The AMA’s in-depth guide to its coding resources provides an overview of a wide variety of products to help accurately seek payment using Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System codes.
Two additional STEPS Forward toolkits, “describe the most recent ambulatory billing and coding guidelines for in-person and telehealth patient care while also providing examples of simplified and efficient documentation to support these coding and billing guidelines.
“By understanding coding and documentation guidelines and simplifying note templates to align with these guidelines, clinic-based physicians can minimize their documentation burden and spend more of their valuable clinic time giving their patients their undivided attention,” one of the toolkits says.
A separate STEPS Forward toolkit explores billing and coding best practices.
The AMA’s "Thriving in Private Practice CME Track" is a free, CME-eligible foundational resource for understanding the business side of practice. A completion certificate is available to AMA members upon completion of the track. A corresponding podcast series highlights the experience of private practice physicians who know the pain points—including payer audits—and can help you navigate these issues and others.
Be efficient in collecting revenue
“Revenue Cycle Management: Streamline and Automate Your Practice's Revenue Cycle” also provides an overview of how to receive all the payment due to your practice. Here are some essentials.
Choose the right practice-management system (PMS). The toolkit includes an 11-page checklist to consider and prioritize requirements for scheduling, filing claims, billing, collections and more for each patient encounter.
“Soliciting input from all staff who use and interface with a PMS and including them in the selection process will ensure that you pick a vendor and product that matches your practice's priorities and needs,” the toolkit says. “A thorough analysis of your practice's revenue cycle process and workflow will provide valuable insight into your system's requirements. Additionally, this type of analysis will help to identify opportunities for automation through the PMS that will improve the efficiency of your practice.”
Make full use of what can be done electronically. As with submitting prior authorization claims, health plan claims can be submitted electronically, and payments can be collected by electronic funds transfer. Determining the status of claims is also easier and faster, as is using an electronic remittance advice in place of a paper explanation of benefits when further action on a claim is warranted.
“Health care claim submission used to require a cumbersome, manual process of completing a paper form, mailing it to a health plan and waiting—sometimes weeks—for a response,” the toolkit notes. “Practices that submit claims electronically save time, eliminate postage and other mailing expenditures, and can more easily track a claim's status. In addition, electronic claims submission often speeds health plan adjudication and payment.”
Pay special attention to prompt patient’s-share payments. The rise of high-deductible health plans means more patient-driven revenue is at stake. Previsit verification of coverage eligibility makes it possible to calculate the price of treatment at the point of care.
The toolkit provides scripts for front office staff to use in discussing payment due with patients. It also has guidance on maximizing patient collections after the time of service, including how to select a collection agency.
The AMA’s “A Physician’s Guide to Effective Revenue Cycle Management” (PDF) goes into further detail on these three phases of getting paid. It also provides five key strategies for effective revenue cycle management, along with case studies with real-world examples of the strategies in action.
In addition, the AMA’s Getting started in private practice webpage provides numerous links to expert resources on payment and contracting topics, including payer audits and disputes, emerging payment models, and health plan/employer contracting.
Also, check out the AMA STEPS Forward® "Introduction to the Business of Medicine" curated collection of resources to strengthen your understanding of contracts, payment models and financial sustainability.
