21 High Street, P.O. Box 219
North Andover, MA 01845
Tel.: (800) 490-0098
Fax: (978) 651-2156

Navigating Successful Practice Management



How do you know which numbers you need to have and which are an option?

It’s Friday morning and you came into the office early to go through the mail and review the latest insurance payments. You’ve sorted through the mail and find that you have received checks from Medicare but there are no EOBs (explanation of benefits) attached to give you the detail of who was paid and for which dates of service.

You take some time to find out why. It seems that somewhere in the past in the many piles of paperwork that you signed for Medicare you checked off the box that asked if you planned to use the ERA (electronic remittance advice) option. This option makes it your responsibility to retrieve the details of the payment from the Medicare bulletin board. Currently, 99% of all Electronic Remittance Advice receivers (providers, clearinghouses, billing agencies, and all others who receive ERAs on behalf of providers) are receiving the HIPAA compliant ERA. Effective October 1, 2006, Medicare will send only HIPAA compliant Electronic Remittance Advice (ERA) to all electronic remittance advice receivers. Now your staff has to go and download the EOB information.

Medicare’s ERA option is just one more requirement being thrown at practices almost daily. Practices today continually need to keep provider numbers up-to-date and fee schedules current. And, which insurances are you “in network” and which are you “out of network”? Which insurance companies provide their own provider number to bill with? Which insurance companies still use your Tax ID number?

And of course, the latest new requirement – is the NPI number – National Provider Identifier number required by every health care provider. As of May 23, 2007, Medicare will only accept, process and pay claims with the NPI number. On October 2, 2006, we will officially be in “Stage 2” of the NPI process. Medicare will accept claims with a legacy number (old provider number) and/or an NPI number and will be capable of sending ERAs with both your old provider number and your NPI number in order for you to track your payments more easily. It is one more task for your already stretched administrative staff to handle.

The new NPI number is much longer than any number used in the past so that the “domino effect” comes into play. There will be new updated 1500 forms. There will need to be software updates to Medical Billing packages to accommodate this number. The format of electronic submission software will need to be modified.

How do you know which numbers you need to have and which are an option? The BIG FIVE insurances – Medicare, Blue Cross/Blue Shield, Tufts, Harvard Pilgrim and Medicaid require their own provider number which you have to apply for and get credentialed for in order to become a provider. A Tax ID Number or Social Security Number is also necessary to be on file to bill for these providers.

The NOT SO BIG others – Aetna, Cigna, United Healthcare, etc. will usually pay against either your Tax ID or Social Security Number and give you the option of being in network or out of network. This will affect your patient population. In network providers have a fee schedule and the patient is usually only obligated to pay a co-pay. Out of network providers can charge what they want, but the burden is passed on to the patient in deductibles, co-insurance and co-pay responsibilities.

All of these numbers are necessary in order to submit your claims to the insurance carriers. Once you have sent in your claims, it is now necessary to track your payments and non-payments to see just what shape your practice is in. Once you have received your payments, it is important to run an aging and review the bottom line, both in amounts and percentages. You should be able to run an aging that will give you current, 31-60 day, 61-90 day, 91-120 day, and over percentages. Your practice specialty, in a lot of instances, will determine just what kind of percentages you want to strive for. The breakdown between over and under 60 days should be your guideline as to how well either your billing person, or billing company is handling your practice. Whether yours is a 90-10, 80-20 or 70-30 split says a lot about both your specialty and your billing and payment processes. It is one more task for your already stretched administrative staff to handle.

How can you and your staff keep track of it all? Depending on the size of your practice, the number of physicians and associates, the “numbers game” can sometimes be too much for just one person to handle. Sometimes “divide and conquer” gets the optimum results. Keeping track of provider numbers, credentialing, negotiating fee schedules, etc. is best handled in-house. The right outside agency can work with your staff on the “bottom line” numbers, your practice can be a winner in the numbers game.

At Bradford Medical Associates we have more than 25 years of experience in every aspect of automating medical practices of every specialty, both large and small. As medical billing specialists, we scrutinize every procedural change and apply due diligence to obtain the maximum reimbursement for all health care services rendered. We bill all of your claims within 48 hours of receipt. The faster your claims are processed, the faster your money flows back into your practice.