In this episode, we'll discuss the administrative issues that private practices deal with on a regular basis, including revenue cycle concerns, payor audits, and prior authorization.
- Prior Authorization and Utilization Management Reform Principles (PDF)
- Fix Prior Auth
- Prior Auth practice resources
- Prior authorization model legislation – issue brief (PDF) and model bill (PDF)
- Payor Audit checklist (PDF)
- Trends in Payor Audits: Part One and Part Two
- Electronic transaction toolkits for administrative simplification
- AMA STEPS Forward® module: Revenue Cycle Management
- Meghan Kwiatkowski, private practice sustainability, AMA
- Taylor Johnson, physician practice development, AMA
Speaker: Hello, and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMA STEPS Forward® program is open access and free to all at stepsforward.org.
Johnson: Hello, and welcome back to the AMA STEPS Forward® Private Practice: Attending to Business podcast, a 10-episode series exploring the business side of private practice. In this series, we talk about how to navigate business operations, and practice efficiency solutions to create and support a thriving and sustainable medical practice business. I'm your host, Taylor Johnson, manager of physician practice development at the American Medical Association. And I'm joined by my colleague and co-host, Meghan Kwiatkowski, program manager of private practice sustainability, also at the AMA. Collectively, we have two decades of experience in private physician practice, and we continue to support physician practices in our current work at the AMA.
Before we start, I want to emphasize that this episode is for general informational purposes and should not be relied on as medical, legal, or other professional advice. Listeners are always encouraged to consult a professional advisor for any such advice.
Kwiatkowski: Welcome to part two of our administrative issues episode. I would like to preface our discussion today with a small caveat, which is that these topics that we'll be discussing today—revenue cycle concerns, payer audits, and prior authorization—are complex and they are hefty. And so while we will touch on overall impact, we do want to encourage our listeners to check out the AMA's website for additional details, as well as for the resources that we'll touch on here in our discussion today. And as always, we'll make sure to link those in the podcast description.
To kick things off, we'll dive right into the topic of prior auth. Taylor, it is well known by our listeners that prior auth is a significant burden both on practices and on patients. While the AMA is deeply involved in advocating for prior auth reform, are there any strategies for practices to generally decrease the burden of prior auth right now?
Johnson: Yes, absolutely. Prior auth is a huge burden, particularly on small practices that don't have the resources that a large hospital or health system would have. One process that really helped the small practice that I was a part of was fine tuning workflow around obtaining prior authorization and checking insurance benefits by utilizing the electronic prior authorization tools that were available to us at little or no cost.
The first thing was to enroll in all of the payers' online platforms, since a majority of them would allow us to submit prior authorization requests and check the status of prior authorizations right through the portal. This allowed my staff to spend maybe 5 to 10 minutes on a prior authorization instead of what could potentially be 30 minutes to an hour on the phone checking prior authorization, depending on wait times when they had to call in.
Kwiatkowski: So key to mention here I think first is, one, I just want to observe that having your staff be able to spend just 5 to 10 minutes on a prior auth instead of potentially 30 minutes or an hour depending on wait times is huge for practice efficiency because you don't tie up staff working on a prior authorization request when they could be doing another task helping a patient.
Then also important to mention here, I think, are the prior authorization and the utilization management reform principles. We have an advocacy department at the AMA that was key in partnering with other organizations to develop these principles. And the principles include five categories which are clinical validity, continuity of care, transparency and fairness, timely access and administrative efficiency, and then alternatives and exemptions. These were released in 2017 by health care professional and patient organizations. And as I mentioned, the AMA was a part of that group.
Practices themselves can be involved in the prior auth reform advocacy efforts and they can visit the fix prior auth website, again linking that in the podcast description of course for ease of access for our listeners. The AMA also has model legislation if physicians want to get involved at the state level, and that can also be found on the AMA's website.
Johnson: Thanks for that, Meg. I think that those are all really important things that physicians can be involved in and really play their part to decrease some of that burden on their staff and in their practices.
Now, I want to transition to another particularly involved and sometimes troublesome area for practices, which is payer audits. Government and commercial payer audits have become a regular occurrence for many practices. First, I want to make it clear that a payer audit does not mean that a practice has necessarily done something wrong. It is a process designed to ensure that practices are keeping thorough records. Essentially, they want to make sure you're doing your bookkeeping. It is so important to comply with the audit requests as soon as they come in, and to use the audit as an opportunity to strengthen your processes. Again, really underscoring it here.
And when your practice receives an audit, or if, it is important for your designated point of contact, which is normally the practice administrator, to respond expeditiously so that any inadvertent delays do not compound the audit. I mentioned earlier that we enrolled in the payer online portal platforms when I was in private practice for prior authorizations. You can also use most of these platforms for payer audits. The audit notification will come into the practice through fax or mail. And I do want to caution, sometimes it will be emailed. So make sure that the practice administrators and physicians are keeping an eye on their email, because we did have one sneak in through there.
Once we received the audit notification, we were able to collect the necessary documentation, and then upload that to the payers online platform. This made it so much faster to get the information back to the payer, so that our payment wasn't delayed if it was a prepayment audit. And it also helped with record keeping, because there were timestamps when everything was uploaded to the portal and exactly what documents were uploaded to support our response to the audit. So if for some reason there was an issue on the payer side, we knew that we could prove that the documentation was uploaded on time and exactly what documentation we sent for the payer to review.
And so I know that this process can be so complicated and so complex, and I know that at the AMA, our advocacy department is doing such a great job with really trying to put out resources to help physicians deal with this process. So Meg, can you talk to us a little bit about those?
Kwiatkowski: Absolutely. We have an online web toolkit that pulls together existing AMA resources, including those advocacy resources that are available, and that are relevant to private practice physicians. And we have a number of them addressing the payer audit process. This includes webinars and checklists on payer audits and dispute trends. We have some podcast episodes where we interviewed physicians and those physicians discuss their audit experience and process recommendations. And so those can be helpful in terms of hearing from practices similar to our listeners, and maybe how they dealt with their audit.
The AMA's CPT team, actually, also has some resources on medical coding audits that can help practices avoid missteps.
Johnson: Thanks for that, Meg. And then equally important to the function of a practice is revenue cycle processes and how they can be made more efficient through electronic transactions. More practices are improving the revenue cycle by accepting electronic remittance advice, or ERAs, which is an electronic version of a paper explanation of payment.
So Meg, can you talk to us just about some of the important steps that practices should focus on when talking about revenue cycle management?
Kwiatkowski: Absolutely. So first, you want to make sure that you're choosing the right practice management system or PMS. You want to consider and prioritize requirements for scheduling, filing claims, billing, collections, and more for each patient encounter. And you want to get input from your staff. I think that's really important to mention as well in terms of the PMs selection, because they will use it. They will be interfacing with it, and including them in the selection process will ensure that you pick a vendor that matches your practice's priorities and meets your staff's needs.
You also want to make full use of what can be done electronically—you mentioned this a little bit, Taylor. And so that applies to both submitting health plan claims and collecting payments by EFT. Determining the status of claims is also easier and faster. And so you want to also see if you, wherever possible, if you can use ERA in place of a paper Explanation of Benefits whenever action on a claim is warranted.
Finally, you want to make sure that you are paying special attention to prompt patient share payments. So the rise of high deductible health plans means that more patient-driven revenue is at stake. And so pre-visit verification of coverage, eligibility, and things along those lines really helps to make it possible to calculate the point-of-care pricing amount.
Johnson: Yes, I completely agree. I think all of those are so important. And so to end our episode today, I want to point out some helpful tools that may help practices feel less overwhelmed by this process. The AMA has several resources around revenue cycle management for practice, and our Advocacy Department has an EFT toolkit. There is also a module focused on revenue cycle management through the AMA STEPS Forward® team. I know we do a lot of work in this area of administrative burden reduction, so we encourage our listeners to check those resources for more details and as always, we will link them in the podcast description.
The tools and resources mentioned in today's episode are linked in the podcast description and available on the AMA website. CME is also available for this episode on the AMA's Ed Hub and linked in the podcast description. I'm Taylor Johnson and this has been Private Practice: Attending to Business. Thank you for listening.
Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA's STEPS Forward® program is open access and free to all at stepsforward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, stepsforward.org.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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