Physical Therapy Billing

Physical therapy billing is often misunderstood and taken for granted by most private practices which result in thousands of dollars lost each month, if not more. Proper PT billing and CPT coding can make or break a practice. Those who know rehab billing secrets and techniques and do it well are more successful overall. Those who do not fully understand billing for physical therapy don't do as well.

What You Don't Know Will Hurt You!

Your billing system is the life blood of your private practice. The billing system keeps the revenue flowing that in turn keeps the business going. Most physical therapists want to treat patients and not deal with the billing. They think it's a "headache" and would rather dump it off on someone like a billing service or company or an employee. As a result of this mentality most practices across the country are losing out on a lot of money! The typical practice collects only 40% of what they should be and could be collecting. Billing is more than generating a claim with diagnosis codes and CPT codes. It is much more than that.

What the Most Successful Practices are Doing

1. They get all the right tools. They don't use borrowed (stolen) forms from past employers and copy someone making a lot of mistakes. They don't use MediSoft, Lytec, TurboPT, PTOS, or Clinicient. Instead they have...

 Good Software with few bells and whistles.

 Good Patient Intake/Registration Form .

 Good Assignment of benefits (AOB) form containing important legal language. It should secure legal rights from the patient allowing you to deposit checks made out in their name, file a complaint with the insurance commissioner on their behalf, receive checks directly from the insurance company on their behalf (even when their policy states otherwise. A good AOB will give you solid legal recourse should the insurance company or the patient ever try to evade payment.

 Good New patient interview form.

 Good Fee slip that's easy to read and understand.

2. They present a bill and collect patient portions at the time of service. They don't waive and discount co-pays and deductibles. Which is illegal without documented financial hardship.

 A good staff member handles the new patient interview with professionalism and tact and the patient is made aware of their financial responsibilities, not a minimum wage receptionist.

 All pertinent personal and insurance information is gathered at initial interview and/or first appointment.

 Services and codes are strategically chosen based on the type of insurance the patient has and the payer rules.

 Modifiers are applied to maximize billing. All staff are trained well on how to use them.

 Patients are presented with a bill with their portions clearly stated and they pay that day.

 The billing person receives the charges and codes daily.

3. They collect insurance portions within 60 days! They don't accept insurance company stall tactics such as, "we don't have record of your claim", "it's being processed", "we need more information", "it wasn't medically necessary", etc. They apply the state and federal provider rights laws and get paid fast.

 Billing data is input into the computer timely

 The AOB is manually sent to the insurance company payer

 Bills are generated and submitted electronically. Electronic claims are paid within 14 days whereas paper claims can take as long as 60-90 days.

 If payment is not made within 30-45 days, a tracer is sent with a notice warning of a possible complaint with the insurance commissioner.

4. They collect 90-100% of Billed Charges! They don't accept denials of any kind such as, "Untimely submission", "Not UCR", "Not Medically Necessary", "No Benefits", and "We sent the check to the patient so go after the patient", etc.

 Appeal letters are sent to the insurance company in response to all denials. (View sample)

 The insurance commissioner and patient are sent a "CC" (copy) of that letter.

 If a reimbursement check is sent to the patient, a demand is made to issue another check referencing the instructions made on the AOB form.

 When a request for "more information" is requested, they charge the insurance company a medical request fee ($35) so they stop using that stall tactic with them. And much, much more...

 If a patient has an outstanding balance owed they don't use weak collection letters, bargain, or write-off the debt. They use collection letters that work and encourage the patient to do the right thing which is to pay the debt!

 They have payment plans available for their patients that are easily setup and administered.

 They make sure to charge patient coinsurance/co-pay's at the time of service each and every visit!

5. They maximize reimbursement! They don't bill every patient exactly the same way. They don't just bill ther-ex, manual therapy, ice and ems (97110, 97140, 97010, 97014) with every patient for a mere $79 reimbursement.

 They use modifiers like -59 and -22 to get paid more for those patients who require more time and energy to treat, such as the patient who c/o neck, shoulder, back, buttock and knee pain.

 They also use the modifier -52 for when services are reduced.
6. They preserve patient loyalty They don't allow insurance companies to maliciously splice the relationship between provider and patient by using derogatory language such as "Fee's are excessive for that geographic region", "Fees are Not usual, customary, or reasonable", "Services rendered were unnecessary or not professional".

 Template letters are sent to insurance companies every time they use derogatory language in the Explanation of Benefits statements to patients/providers.

 The insurance commissioner and patient are sent a "CC" (copy) of that letter.

 They collect patient coinsurance/co-pays at the time of each visit so the patient won't have to later pay a lump-sum-bill three weeks after discharge which most people can't pay and quickly come to resent.

Studies show that patients who owe you money are more likely to file a malpractice suit against you. Studies also show that patients who pay something out-of-pocket for their healthcare services each visit get better faster.

Billing Options Available

1. Contracting out to an independent medical billing service

Most of the so called "medical billing services" are stay-at-home moms who took a weekend course on "How to Make $40,000/yr Working From Home". They learn how to purchase software, collect and input data and submit claims. They're also taught how to print business cards and present themselves as a professional organization. The problem is most of these individuals have little to no experience.

PROS Cheaper and more personable. Allows you time to market and advertise your services.

CONS Lacks experience. Most likely won't know how to appeal denials or respond to stalling tactics. Most likely paying for simple data entry.

CHARACTERISTICS

o No setup fee.

o 4-10% of gross reimbursements.

o They collect patient info and billing by fax, Fed-Ex, or PC Anywhere

o Not very good about updating you on status of claims and collections

o Reports are not very good

Results typically are 40-50% of money lost by falling through the cracks and never getting appealed and collected. Most do not know how to appeal denials, file complaints with the insurance commissioner, respond to derogatory language in EOB's, train your staff on modifiers and good coding for different type of payers, or respond well to insurance company tactics on stalling and refusing payment--all the things that make a billing system great.

If you want to find a decent billing person, one who is organized and knows the basics, ask them these questions:

o Do you have any physical or occupational therapy billing accounts now?

o Can I contact them for reference?

o Can you send me a sample of 3 reports?...monthly claims submitted, monthly paid items posted, aging report on every outstanding claim.

o What type of billing software do you use? Is it HIPAA compliant?

o How will you collect the charge/patient data from me?

o Will you teach me code strategies for each payer type (ie. workers comp, blue cross, medicare, medpay, etc)?

2. Large Medical Billing Companies

The larger medical billing companies usually work with many providers and have many accounts. They typically have more experience but that is no guarantee they know how to go beyond data entry, claims submissions and payment postings either. There is not much money in it for them to appeal denied claims because it takes human resource and time to write letters, make phone calls, and submit complaints. They would much rather do the simple data entry and get their percentages from that.

PROS Reports are better. They have more experience. Allows you time to market and advertise your services.

CONS More expensive. Probably won't do all appeals, letters to insurance commissioner and patients especially if you are a small account (less than $10,000 per month).

CHARACTERISTICS

o Setup fee

o 8-15% of gross reimbursements.

o They collect patient info and billing by website log-in, fax, Fed-Ex, or PC Anywhere

o Not very personable

Results typically are 30% of money lost by falling through the cracks and never getting appealed and collected. Most will not file complaints with the insurance commissioner or respond to derogatory language in EOB's.

If you want to find a good billing company, one that appeals denials, files complaints with the insurance commissioner, provides detailed reports of claims submitted monthly, claims paid monthly, and aging reports with 30-60-90-120 day statuses then make sure to screen them well. Ask the following questions:

o Do you have any physical or occupational therapy billing accounts now?

o Can I contact them for reference?

o Can you send me a sample of 3 reports?...monthly claims submitted, monthly paid items posted, aging report on every outstanding claim.

o How will you collect the billing/patient data?

o Will you teach me code strategies for each payer type (ie. workers comp, blue cross, medicare, medpay, etc)?

o Do you appeal denials?

o Can I see sample appeal letters that you use?

o Do you ever send patients letters? If so, what and can I see a sample?

o How do I ask you questions? What are your support hours?

Prices are always negotiable with outside billing companies and independents but be ready to pay if you want them to do everything listed above.

3. In-house billing where an employee does the billing

I recommend doing billing in-house with an employee after a year of solid marketing, advertising, and promoting your practice. Most owners do not have the time necessary to do both adequately (as well as treat patients). If you are considering hiring an employee to do the billing be prepared to learn the in's and out's first. Even if the employee boasts about knowing billing. It's a good idea to learn it yourself, setup the system, and work closely with the employee until they demonstrate competency.

No one will go after the money owed to you and look out for the welfare of your business like you.

PROS More control over the system. Better collection rates. If monthly billing is more than $20,000/month you will save money by using an employee versus an outside service. They can also assume other admin tasks.

CONS Takes time to learn the system and set it up.

CHARACTERISTICS

o Employee wages

o Employer taxes

o More control over billing procedures Results typically are less than 10% of money lost. Less money will fall through the cracks and get lost. Complaints with the insurance commissioner will get filed and derogatory language in EOB's will get responded to.

If you want to find a good employee, one that will do the job well, you may want to hire someone who tried to start an independent billing service at one time. It's not necessary but they may already know the basics. Ask them these questions?

o Do you have any experience with medical billing?

o How much do you think this job should pay? Look for someone in the $12/hr or more range.

o What type of work do you enjoy more, office work or person-to-person work?

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