Podiatry Billing and RCM: The Essential Guide
Practice with confidence you’ll get paid
A reliable billing partner ensures that every area of your practice runs more smoothly. Here’s what you need to know
Billing and revenue cycle management in podiatry is basically a highly detailed accounting process, with many quirks and idiosyncrasies. In our experience, most physicians, in all areas of practice, underestimate what is required to navigate this process successfully.
Since many podiatrists are independent practitioners, billing and RCM take on additional urgency. Providing essential care, improving patients’ lives, alleviating their issues are all part of every doctor’s everyday routine. But on top of that, independent practice owners and partners need to worry about getting paid.
If you’re and independent owner or partner, billing and RCM are ultimately your responsibility. But of course, that doesn’t mean doing the work yourself. Rather, you need to assemble a team of skilled people on your team, whether in-house or an outside partner.
Each specialty has its own unique challenges.
The Mindset of an Independent Business Owner
While physicians often struggle to bridge the gap between the clinical and business aspects of their practice, we find this is somewhat less of an issue for podiatrists. In other specialties, its astonishingly common for practitioners to let billing & RCM get to a very bad state. We have several clients in other specialties who, before they began working with us for RCM, were losing several thousand dollars daily to billing issues, that were completely avoidable! They knew they were losing money, but they were so focused on caring for patients that they didn’t feel like they had time to address it.
For many of our new clients, the first thing we have to address is business mindset. However, for podiatrists this is often less of an issue, since many podiatrists have been independent business owners for much of their careers already.
Understand the Steps of RCM in Specialty Practice
In podiatry, as in any specialty practice, patient encounters follow a predetermined sequence, with each subsequent step dependent on those that come before it. Practitioners need to understand the significance of each step for billing and RCM, as well as from a clinical perspective.
STEP 1: OBTAIN REFERRAL FROM PRIMARY CARE PROVIDER
Most patients’ healthcare coverage is through an HMO. In these cases, whether the patient has a hangnail, severe athlete’s foot, symptoms of diabetic neuropathy, or any number of other conditions, their initial step will be to visit their PCP. If the PCP determines that their condition requires a specialist, they refer the patient to you.
In the HMO scenario, referral from the primary care practitioner is the first step of the billing process. Once you receive the referral, you share it with your biller, and they record and track it.
Remember, every step of the RCM process depends on what comes before it.
The referral hinges on the PCP’s evaluation of medical necessity, and each subsequent procedure requires both demonstration and documentation of medical necessity. If the patient’s insurer determines that the criteria for medical necessity are either not met, or not documented, that will usually be enough for them to deny the claim.
STEP 2: INITIAL APPOINTMENT & EVALUATION OF PATIENT
Once the patient comes in for their appointment, you can determine what type of care is required, if any. Perhaps you’ll recommend a surgery or some other procedure. Perhaps a change of medication will be sufficient, or perhaps you’ll refer the patient to a physical therapist, and no procedure will be immediately necessary.
If after the initial evaluation, you determine additional intervention or medication is appropriate, you will of course document your evaluation and recommended course of treatment in your EHR.
Your biller must now fulfill several new tasks:
A reliable billing partner will allow you to schedule procedures at the earliest possible time, with full confidence you’ll be paid.
Deliver your EHR notes to the patient’s insurance provider
Ensure your recommendations are within the parameters of “medical necessity” as determined by the patient’s insurance
Obtain an authorization or approval from the patient’s insurance to cover your recommended course of treatment
From your perspective as a physician, all of this occurs in the background, as you proceed with treating and caring for your patient. In our experience, most physicians will proceed with treatment on the assumption that their biller has everything in order, and that they will be paid.
From a clinical perspective, treating the patient ASAP is clearly preferable, but from a business perspective, there is a risk of not getting paid if your biller makes any mistakes. That’s one reason a reliable billing partner is so important for a successful practice.
STEP 3: DETERMINING MEDICAL NECESSITY
In theory, it would seem like the “medical necessity” of care should be exclusively, or at least primarily, determined by the physician. In reality, however, the patient’s insurance company has an independent process for evaluating the medical necessity of each course of treatment.
Each insurer has its own specific definition of medical necessity, both in general and for specific procedures and courses of treatment. These definitions are somewhat different for different types of practitioners. In real life, you’ll never be able to keep track of all the minute changes. Rather, it’s your biller’s job to keep up with changing requirements, ideally in a proactive manner.
From the insurance company’s perspective, a claim of medical necessity usually rests on a number of different criteria, such as:
The patient having insurance for at least a minimum period of time
The patient experiencing their health issue for a minimum period of time
The patient’s health issue being the result of an underlying condition
The physician having attempted other interventions, which have not resolved the patient’s issue thus far
The above are some examples, and there may be others, depending on the specific course of treatment for each specific patient. In terms of demonstrating and documenting “medical necessity,” the key thing to understand is that your clinical notes must specifically fulfill all of the insurance company’s criteria for approving that specific course of treatment. On the insurance company’s side, an auditor, rather than a physician, is most likely responsible for making these evaluations of medical necessity, although physicians will certainly be involved in setting the parameters for such evaluations.
For a good a general overview of this topic, the AAFP has a good guide to the concept of medical necessity. Although published some time ago, it still covers the essential concepts very well.
STEP 4: DEMONSTRATING AND DOCUMENTING MEDICAL NECESSITY IN YOUR CLINICAL NOTES
If the patient’s insurance company reviews your notes, and for some reason determines that your recommended course of treatment doesn’t meet their criteria for “medical necessity,” your claim will be rejected. Often, you will have already done the procedure before you learn the claim has been rejected.
Often, claims are rejected due to issues with the clinical notes in the initial evaluation. Different insurance companies have different requirements for what information must be included in that note to demonstrate medical necessity. By itself, this might seem confusing. What’s more, insurers may change these requirements may change at any time.
In practical terms, it’s impossible for physicians, and even the best billers, to keep up with changing requirements of individual insurance companies related to medical necessity the full range of possible procedures. Nevertheless, a robust billing process will ensure you get paid despite changing requirements.
You should work with your biller to ensure the following:
Use detailed and comprehensive, customized templates in your EHR notes, to ensure you include all required information and meet criteria of different insurers
If a claim is rejected, your biller should immediately contact the insurance company to determine the specific reason for the rejection
Your biller should ensure you make edits and updates to your clinical notes ASAP, so the claim can be rebilled
Once you understand the insurance company’s new requirements, should update the global template in your EHR to include any necessary information
In practice, you can update your notes and rebill each claim as many times as necessary. However, each rejection causes a delay in payment, and requires more work from you and your team, so you should strive for efficiency.
STEP 5: PERFORMING THE PROCEDURE AND COURSE OF TREATMENT
From a clinical perspective, it’s extremely important that billing issues don’t hinder you from providing care. From the time you first evaluate a new patient, you should be free to follow the best course of treatment you possibly can.
For example, if you have a diabetic patient who is in pain, and you determine that treatment with a nerve blocker is medically necessary, you should be fully empowered to schedule and perform that procedure at the earliest possible time. However, it must be noted that this involves a significant up-front expense on your part, for both the medication and operation of equipment.
Your biller must ensure that the demands and urgency of providing care do not conflict with the necessity of getting paid for this care. You should never find yourself wondering whether you’ll be paid for a procedure or course of treatment. If the patient is covered, you should be able to proceed with full confidence that the billing process will be managed successfully. If for some reason the patient is not covered, you must be made aware of this in advance, so you can choose the best course of action.
STEP 6: WAITING FOR CLAIMS TO BE PAID
If your billing service is doing its job, you should receive payment within a predictable time frame.
What does this mean exactly?
As much as possible, you should try to quantify the effectiveness of your billing process. Some key reports to review include:
If your billing service is doing its job effectively, these numbers will reflect it.
The Role of an Effective Billing Service
A skilled and diligent medical billing partner will dramatically reduce and often eliminate unpaid claims from insured patients.
In our experience, many physicians, across all specialties, often perform procedures without full confidence that they’ll be paid. This may be less common among podiatrists, but it does happen. Patients often come to you in pain, and the humanitarian imperative to help them overrides concerns about billing and insurance. This is understandable, even noble, but for a business owner it’s not a sustainable business practice.
We always emphasize to our clients that physicians should not bear the financial burden of billing issues. Insurance providers exist for the purpose of paying health expenses. You should never have to wonder whether you’ll get paid, especially not due to internal billing issues.
If you have questions about your current billing situation, we offer a free, no-obligations revenue analysis to help you better understand your revenue and collections. Get in touch with us to learn more