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Medical billing complexity and massive volumes of daily claims render manual claims processes incapable of protecting both the provider and the payer from underpayments, overpayments, and billing compliance violations. Straight-Through Billing (STB) addresses complexity and volume processing problems by automating the majority of the claim flow and focusing the billing follow-up specialists on exceptions only. An STB process flags problems, routes them for follow-up, and enables online correction and resubmission. The STB methodology implements billing service transparency and focuses management on strategic process improvement opportunities.  Straight-Through Billing integrates the billing process into the practice management workflow, automates the vast majority of transactions, focuses manual labor on exceptions, and establishes a process for continuous improvement.   Remember:  Straight-Through Billing offers a comprehensive approach to improving the billing process, integrating various components, and promoting continuous improvement.  Practice Management Integration  First, integrated practice management and billing workflow connects patient scheduling, medical record management, and billing into a single process. Every participant in the practice management workflow receives a unified and coherent picture of the practice workload, patient and provider location, resource availability, and cash flow. However, integrated with Electronic Health Records, practice management systems are more beneficial. Electronic health records (EHR) are digital formats of a patient’s chart. They contain all the information about a patient’s health. This includes medical history, allergies, immunizations, previous treatments, medication history, past diagnoses, history of substance abuse (if any), and so forth (Shah, 2021).  Transaction Automation   Transaction automation streamlines and expedites the billing process by automating claim validation, payer message reconciliation, and billing workflow management:   Automated claim validation eliminates errors downstream and reduces processing time because it flags errors before submitting the claim to the payer.   Automated claim message reconciliation eliminates the costly search for the original claim and standardizes message communication, eliminating the need to decipher the (often cryptic) payer’s message.   Automated billing workflow management drives the follow-up discipline required for the resolution of claim denial and underpayment incidents, and it establishes a high degree of process transparency for all billing process participants, resulting in full and timely payments.   Automated billing increases the net collection rate due to quick claim turnaround and efficient follow-up. Respond to your denials within 5-21 business days of receiving them, using our Daily Denial Email Alerts (Qureshi, 2022).   Focus on Exceptions   Focusing manual labor on exceptions requires timely exception identification, routing to follow-up personnel, online error correction, and rigorous follow-up tracking. Again, process transparency enables tracking exception follow-up as implemented in ClinicMind-like systems. Another significant benefit of automated medical billing is the ability to track and analyze financial data. With this, healthcare facilities can monitor their revenue cycles, identify growth opportunities, and generate detailed financial reports (Polo, 2023). Continuous Process Improvement   Finally, a process for continuous improvement requires continuous observability of every process attribute and a modification methodology for both automated claim processing and manual exception follow-up tracking.  Straight-Through Billing implements billing transparency by design because billing transparency is an integral attribute of every component of the STB process.  It also enables businesses to streamline their billing operations, reduce errors, enhance efficiencies, and improve the customer experience (Ward, 2023).  Straight-Through Billing Architecture    The Straight-Through Billing systems architecture mirrors the architecture of general Straight-Through Processing (STP) systems developed for the financial services industry. Such systems require effective workflow management, a knowledge-based validation system, connectivity to all process participants (including online data reconciliation), and tracking of problem resolution. Therefore, a typical ClinicMind-like STB system has a three-tiered architecture:   Back-end processing engine, designed for a high-volume transaction processing environment   Middle tier, using Java Servlet technology   Front end, using an HTML-JavaScript, zero-footprint client     Did You Know?  The STB architecture is inspired by the systems used in the financial services industry, showcasing the transferability of advanced processing concepts across different domains.  An STB system (e.g., ClinicMind) based on the methodology outlined here implements rich functionality, which allows the following to be automated:   Computer-aided preferential patient scheduling   Integrated electronic medical records   Online computer-aided coding   Real-time claim validation and patient eligibility testing   Electronic claim submission   Payment posting, reconciliation, and verification of meeting contractual obligations   Monitoring of audit risk and billing compliance   Tracking of denial appeal process     Quantitative STB Management    Straight-Through Billing methodology allows for quantitative management since the likelihood of the entire process failing can be estimated as the product of such items for each individual workflow step. A ClinicMind-like STB system tracks the percentage of clean claims (claims paid in full, and within the allocated time frame, without any manual intervention) and focuses the management on those process aspects that yield the greatest potential improvement. Thus, STB methodology focuses on exceptions at both the tactical and strategic management levels and can help to improve cash flow and reduce outstanding invoices by providing real-time visibility into billing and payment status (Mielnicki, 2022).  Modern Insights and Research In the ever-evolving field of medical billing, staying ahead of the curve is crucial for achieving financial excellence in the healthcare industry. Let’s embark on an exhilarating journey into the future of medical billing, where the convergence of electronic health records (EHRs), artificial intelligence (AI), real-time analytics, and collaborative efforts reshapes the revenue cycle landscape. Brace yourself for a transformative exploration that revolutionizes processes, enhances data accuracy, maximizes financial outcomes, and ushers in an era of unparalleled efficiency and effectiveness in the dynamic realm of medical billing.  1- Role of Blockchain Technology in Billing Systems The seamless integration of electronic health records (EHRs) and billing systems is revolutionizing the field of medical billing. Gone are the days of fragmented medical records scattered across various healthcare organizations. With blockchain at the helm, a distributed EHR ecosystem emerges, ensuring a smooth flow of information between providers. By eliminating manual data entry and ensuring accurate documentation, this innovative technology guarantees accurate and secure documentation, eliminating errors and speeding up reimbursement processes (Cerchione et al., 2022). But that’s not all. Blockchain brings an unparalleled level of data integrity and security, employing cryptographic techniques to safeguard patient information from prying eyes.

When patients miss appointments, they interrupt the flow of patient care, impede clinic productivity, and signal an eroding patient loyalty. The rate of no-shows runs at 30% for the average family practice. A missed appointment amounts to missed billing revenue. Worse, if clinicians are part-time or full-time staff rather than contracted, they sit idle on the company clock, losing money with each passing minute. Finally, a missed appointment could be a symptom of a deserting patient, signaling a potential loss of long-term billing revenue. Most clinics lose an average of 20% of their revenue due to missed appointments. Lost revenue may not be the largest problem caused by no-shows. Other problems span health damage, patient liability risks, reduced accessibility, and impeded resident education. Rigorous no-show management methods using advanced technologies integrate scheduling and billing data, reduce no-show rates and improve associated revenues by more than 50%. They also mention the comparable improvement of long-term patient loyalty (Hashim et al., 2001). No-Show Impact on the Clinic Figure 1. No-Show Impact (Hayhurst, AthenaHealth) A missed appointment poses five kinds of problems: Health damage – A patient’s health can be damaged due to interrupted continuity of care or a missed opportunity to solve an acute health problem. The doctor also loses an opportunity for a timely review of patient health, treatment progress, etc. Liability risk – A patient who misses an appointment and suffers an injury may have a viable cause for a lawsuit against the practice. To avoid such risk, the doctor must maintain evidence of giving clear directions and making reasonable efforts to ensure the patient’s compliance with the care program, including keeping follow-up appointments. Reduced accessibility – Other patients are postponed and don’t get access to care because of a no-show or canceled appointment. Impedance to medical education – A resident or intern misses an opportunity to learn and improve care skills. Loss of revenue – The clinic cannot make up revenue due to missed appointments. A financial impact arises from wasted resources, such as staff time, equipment, and facility utilization, that were allocated for the no-show patient. No-Show Frequency Distribution No-show rates average about 20%: 10% of clinics have less than 10% no-shows, 42% of clinics have 10%–20%, 34% of clinics have 20%–30%, and 14% of clinics have more than 30% no-shows (Izard, 2005). Further, the top 10 clinics regarding the lowest no-show rates range from 3%–9% for no-shows, while the bottom ten clinics reach 33%–57% (Moore et al. 2001). Common reasons behind No-show  Forgetfulness: Patients may simply forget about their appointments due to a busy schedule, lack of reminder systems, or cognitive factors. Transportation issues: Lack of transportation or difficulty accessing reliable transportation can prevent patients from attending appointments. Fear or anxiety: Some patients may experience fear or anxiety related to medical procedures, test results, or hospital settings, leading them to avoid or cancel their appointments. Financial constraints: Financial limitations, such as the inability to afford healthcare services or medications, may result in patients skipping or postponing appointments. Illness or emergencies: Patients may have unexpected illnesses or emergencies that prevent them from attending their scheduled appointments. Lack of awareness or understanding: Patients may not fully comprehend the importance of their appointments or the consequences of missing them, particularly for follow-up care or chronic conditions. Language and cultural barriers: Language barriers or cultural differences can impede effective communication and understanding, leading to missed appointments. Long waiting times: Lengthy wait times at hospitals can discourage patients from attending appointments, particularly if they have competing priorities or other time constraints. Stigma or fear of judgment: Patients with certain medical conditions or mental health issues may experience stigma or fear of judgment, causing them to avoid seeking care or attending appointments. Personal or work-related conflicts: Conflicts arising from personal commitments, work schedules, or other obligations may interfere with appointment attendance (Marbouh et al., 2020). The image below shows common reasons for missed appointments (Saif et al., 2018).   According to a study, among all patients, those who never have a no-show appointment have an attrition rate of slightly less than 19 percent. In contrast, almost 32 percent of patients with one or more no-shows do not return to the same practice within 18 months  (Hayhurst, AthenaHealth). Three-Phase No-Show Management Strategy An effective no-show management strategy is based on tracking, rescheduling, and follow-up: Tracking Record all no-shows and reconcile them with billing daily. Record no-show reasons and follow-up notes in patient records. Review end-of-day reports daily. Rescheduling in real-time Allow patients to request appointments online using the Internet Overbook and use waiting lists. Fill new openings with walk-ins or patients from the waiting list. Follow-up Activate a sequence of reminder calls/emails to all patients ten days, two days, and one day before their appointments.  Place follow-up calls to determine reasons for no-shows and reschedule the patients. Reminder calls for upcoming appointments and follow-up calls on recent no-shows are effective strategies for billing revenue protection because they reduce the number of no-shows and help early identification of incipient patient attrition and other patient-related problems (Hashim et al., 2001). Follow up with warning letters after one no-show.  Dismiss patients from the practice after three no-shows.   Reminder calls or emails before an appointment remains the most effective method to prevent missed appointments. Additionally, sending reminders via email and allowing patients to confirm online turns an office reminder into a patient’s action item, significantly outperforming the impact of a voice message or postcard. While recognizing the benefits of reminder calls, busy practice owners often neglect or postpone reminder and follow-up calls because of other office management priorities, such as personnel issues or billing. As with any other management initiative, a reminder call strategy must be implemented systematically and consistently to get results. Note that outsourcing reminder calls to calling services and using the Internet reduce the cost of reminders. Therefore, reaching all patients before their appointments makes good business sense. Ways to reduce No-shows Automation of appointment reminders: Implementing automated appointment reminders can significantly reduce

Update – March 29, 2024 We understand the challenges the Change Healthcare outage has brought, especially with delayed payments and confusing updates. Here’s how we’re addressing these issues: Payment Delays: We’re working tirelessly to manage these delays. Remember, if our work doesn’t result in your payment, it’s free. Clear Communication: We’ll continue to provide regular, straightforward updates to cut through any confusion. Solutions in Action: Manual Processing: We’re working on getting paper claims submitted. Automated Approaches: We’re working on securing EDI approvals for efficiency. Your Role: Please promptly sign and return any forms sent via task by our enrollment team for ERA processing. We’re in this together, and our commitment to your success is unwavering. Thank you for your patience and trust in ClinicMind.   Update – March 25, 2024 As you know, the current CHC outage is impacting our ability to send out paper patient statements, which currently remain on hold. Given these challenges, we strongly encourage the transition to electronic statements (e-statements). The CHC outage did not affect e-statements, which are available for those using Fortis or Cash Practice as their credit card merchant. To set up e-statements, please contact us to update your account if you have any questions about this process. Our team is ready to assist you in making this transition as seamless as possible. Thank you for your continued cooperation and understanding during this difficult period   Update – March 20, 2024 Today’s update regarding our ongoing situation with Change Healthcare is as follows: There is still uncertainty about when Change Healthcare will resume accepting claims. In light of this, we continue to re-enroll practices through alternative clearinghouses. This is a crucial step in ensuring our operations continue smoothly during this period. In addition to this, we are actively exploring additional submission paths. Our team is collaborating with our current partner vendors to identify alternative solutions in cases where our existing clearinghouses may not be viable options. Our primary focus remains on getting claims submitted efficiently and effectively. Alongside these efforts, we also focus on redirecting practices? Electronic Remittance Advice (ERA). This is an important aspect of our overall strategy to maintain seamless financial operations. Your patience and understanding as we navigate these challenges are greatly appreciated.   Update – March 14, 2024 Change Healthcare (CHC) recently provided updates on their services, necessitating some clarifications. Regarding Electronic Payments (ERA), it was initially expected that CHC’s system would be back online by 3/15. However, this date specifically refers to CHC processing payments from insurance companies to practices, and not to the resumption of ERA services. In terms of Claims Submission, the initial hope was to resume submissions by the week of 3/18. According to the latest information from CHC, this process is now expected to take several more weeks. The delay is due to the ongoing transition of enrollments to Optum?s alternative clearinghouse, extending the timeline beyond initial estimates. Accordingly, in response to these delays, we are actively pursuing the alternative payer strategy initiated at the beginning of last week. To date, we have submitted a significant number of claims and have diligently followed up on a majority of payments. This proactive approach is aimed at mitigating the impact of the current situation. We will continue to provide updates as more information becomes available.   Update – March 11, 2024 Major Update on Claims Processing We are happy to announce a few updates to the ongoing cyberattack at Change Healthcare and subsequent effects it has had on our abilities to process claims. Change Healthcare predicts a potential resumption of claim processing by March 18, 2024. However, as full operational capacity isn’t guaranteed by this date, they are set to launch electronic payment functionality from March 15th. This development is crucial as we await the reconnection of ERA services. In the meantime, our team is actively pulling remittance advice through payer portals, we’ve successfully updated all payers that don’t require additional enrollments, and we are now focusing on payers needing enrollment. This effort requires gathering contact information to initiate enrollment and ensuring providers promptly receive and return the required forms. Your cooperation in promptly returning requested forms will greatly assist in expediting this process for your practice. This effort is key to maintaining our high service standards and minimizing disruptions. Thank you for your continued trust in ClinicMind.   Update – March 7, 2024 We are pleased to share some positive developments as we navigate through the challenges posed by the Change Healthcare/Optum outage: Efficient Claim Resubmission: We’ve successfully transitioned all claims previously on hold (Temp_Hold) due to the outage. These claims are now in the ?Valid? category and have been resubmitted wherever we?ve identified viable alternative routes. Expansive Payer Network Update: Our team has diligently updated the submission pathways for over 600 payers, ensuring that claims are processed through these new, effective channels. Ongoing Strategic Efforts: Our commitment to resolving this issue is unwavering. We are actively exploring and establishing alternative pathways for the remaining payers, ensuring a comprehensive and robust solution to this challenge. Significant Progress in Claim Submissions: Despite the unexpected outage, we’ve made remarkable progress in claim management. To date, we?ve successfully submitted 75% of the total insurance claims that were impacted by the outage. We appreciate your patience and understanding as we continue to work tirelessly to mitigate the impact of this outage. Our team is dedicated to maintaining the highest standards of service and efficiency during this period. Stay tuned for further updates as we forge ahead.   Update – February 29, 2024 As we continue to navigate the ongoing system outage at Change Healthcare, we want to provide you with the latest updates and address some new questions that have arisen. We understand the challenges this situation presents and appreciate your continued patience and understanding. Persisting Problems Change Healthcare, the largest healthcare clearinghouse in the country, has been experiencing an outage since February 21, 2024. This is a nationwide issue, affecting not just our services but many others across the country. Claims,

What is outcomes-based compensation in healthcare? Compensation plans in the healthcare industry have undergone a paradigm shift, with more providers moving away from volume-based to outcome-based compensation for their employees. This is partly attributable to the rising healthcare costs and enhanced patient empowerment, with a growing need for better quality of service delivery (Zigrang, 2022). Volume-based models compensate providers for the quantity of care delivered rather than the impact on the health status of patients (Tai et al, 2014). The vision for outcomes-based compensation in healthcare revolves around incentivizing and rewarding healthcare providers based on the outcomes they achieve in patient care rather than just on the volume of services delivered. This approach aims to improve the overall quality of care, enhance patient outcomes, and reduce healthcare costs. However, existing literature on outcomes-based compensation models shows mixed results in terms of impacts on quality of care and costs, with some reporting significant cost savings and others reporting increased costs of care, as expounded later on in this chapter. In an outcomes-based compensation model in healthcare, providers are encouraged to focus on delivering measurable results and positive patient experiences. This may involve achieving specific health outcomes, such as reducing hospital readmission rates, improving patient satisfaction scores, or effectively managing chronic conditions. By aligning compensation with outcomes, healthcare organizations aim to drive better patient outcomes, ensure patient safety, and enhance healthcare delivery. Healthcare outcomes reflect the quality of care offered by practice and remain stable over time compared to process measures, which keep changing over time. For instance, the target outcomes in a diabetic care clinic include reduced blindness, reduced amputation rates, improved self-management and confidence, and reduced heart attacks.  These target outcomes that matter to patients the most tend to remain stable over time regardless of where you practice. On the other hand, process measures such as fundoscopic examination, blood glucose assessment, foot care, and medication review may vary over time. This forms one of the basis for outcomes-based compensation models (Dunbar-Rees, 2018). The outcomes-based compensation model offers several benefits to different players in the healthcare field. Patients get to enjoy quality care over volume, with the potential to address health inequalities. This is so because the model emphasizes outcomes that matter to patients, which tend to remain constant regardless of the geographical location. For instance, the target outcomes for a diabetic care clinic in Kisumu, Kenya, Africa, would be more or less the same as for a clinic in Atlanta, Georgia, USA. For the providers, outcomes-based compensation helps reduce the wastage of resources and unnecessary interventions by enabling efficient resource allocation. It also reduces fragmentation of care by encouraging collaboration and coordination across clinicians and specialties. The payers benefit through reduced wasted healthcare spend as well as focusing on buying healthcare that is based on outcomes that matter most to their beneficiaries (World Economic Forum, 2023). The outcomes-based model has been implemented across different healthcare facilities worldwide in a bid to improve the quality of care and reduce costs. There are several studies showing the impact of outcomes-based models on the quality of care, resource utilization, and healthcare costs. These studies show varied outcomes, with some reporting positive impacts and others reporting negative impacts or no significant impacts. For instance, the Pioneer Accountable Care Organizations (ACO) implemented by the Center for Medicare and Medicaid Services in the USA as an outcome-based compensation model reported a reduction in healthcare costs by approximately $385M in two years compared to the previous volume-based compensation model, with no difference in quality of care (McCarthy, 2015). The Medicare Shared Savings Program, which was also designed to incentivize cost reduction, reported similar cost savings of $385M dollars over one year of implementation (Eijkenaar & Schut, 2015). However, some studies suggest that outcomes-based models were associated with additional healthcare costs, mainly in the form of bonuses and incentives paid out to healthcare workers. For instance, the Quality and Outcomes Framework (QOF) implemented in the UK as a pay-for-performance program was reported to have spent about US $9 billion on incentive payments over a period of just seven years (Ryan et al, 2016). Outcomes-based compensation models impact on the quality of care delivered to patients, albeit to varying extents from the available literature. In one study, the Quality and Outcomes Framework model operationalized in the UK to incentivize family practitioners for target patient outcomes resulted in an increase in the median practices achieving the target HbA1C levels for diabetic patients from 59% to 66.7% in two years. (Vaghela et al, 2009). However, another study evaluating the impacts of the same Quality and Outcomes Framework in the UK on hypertension reported no significant change in blood pressure monitoring rates and treatment intensity attributable to the program. There was no significant difference in the cumulative incidence of stroke, renal failure, and heart failure as well (Serumaga et al, 2011). With such mixed data on the impacts of pay-for-performance on costs and outcomes, it is evident that this alone may not be sufficient to improve the quality of patient care, and more factors need to be accounted for in order to achieve optimal patient care quality. Another study in rural Kenya evaluated the utility of outcomes-based compensation models in improving the management of suspected malarial fevers. The program rewarded measures of process quality of care, including the proportion of patients correctly given antimalarial drugs based on test results. Incentives were provided to facilities with increased rates of treatment for confirmed malaria cases, as well as those with reduced treatment rates without any confirmatory tests. From the study, the odds of receiving treatment following a negative malaria test in the intervention arm was 0.15 relative to baseline, compared to 0.42 in the comparison facilities that were not enrolled in the program. This translated to a 2.75 times greater reduction of inappropriate prescription of antimalarial drugs in the incentivized groups compared to the comparison groups (Menya et al, 2015). Another instance in which the outcomes-based model has been utilized is through Humana’s

Credentialing in medical billing is crucial for ensuring patient safety and maintaining the quality of care provided by healthcare providers. This process involves verifying providers’ qualifications, competence, and eligibility, playing a vital role in effective revenue cycle management. In 2021, the Credential Management Solutions Market had a valuation of USD 833.45 Million. Projections indicate that it is expected to reach USD 2526.34 Million by 2030, experiencing a compound annual growth rate (CAGR) of 17.7% from 2022 to 2030. The rising cyber threat risk has spurred demand for skilled experts, credential management solutions, and IT security compliance software in businesses and organizations. (Credential Management Solutions Market Size, Share, Trends & Forecast, 2023) Figure 1. Global Credentialing Management Solutions Market https://www.verifiedmarketresearch.com/product/global-credential-management-solutions-market-size-and-forecast-to-2025/ Medical Billing Systems in Credentialing Medical billing systems are critical components of healthcare operations. They are used to submit and follow up on claims with health insurance companies to receive payment for services rendered by a healthcare provider. The role of medical billing systems in credentialing is quite significant. 1. Provider Information: Medical billing systems hold essential information about providers, including their credentials. This information is necessary for filing claims and verifying a provider’s ability to provide certain services. 2. Claims Processing: One of the key steps in processing medical claims involves verifying the provider’s credentials. If a provider is not properly credentialed with a particular payer, claims for services rendered can be denied, resulting in lost revenue. 3. Regulatory Compliance: Medical billing systems help maintain compliance with healthcare regulations, including credentialing-related ones. By ensuring providers are credentialed properly, the systems help prevent fraudulent claims and avoid potential legal issues. Integrating credentialing into medical billing systems can streamline workflows, improve accuracy, and increase efficiency. The integration can occur in various ways: 1. Data Sharing: Medical billing systems can be configured to share data with credentialing systems, allowing for real-time updates of provider information. 2. Automated Verifications: With the integration, systems can automatically verify a provider’s credentials during claim processing, flagging any issues for immediate attention. 3. Credentialing Updates: Updates to a provider’s credentials can be automatically reflected in the billing system, reducing the chance of claim denials due to outdated credential information. 4. Scheduling and Alerts: Medical billing systems can help manage credentialing timelines, offering reminders when it’s time for providers to renew their credentials, thus maintaining their eligibility with payers. Key Facts about Credentialing Applications Credentialing applications in the US healthcare system involve a significant volume of submissions. However, the success rate varies, with some applications failing to meet the requirements. The timeline for the credentialing process typically spans around 90-120 days, including the verification and contracting phases; per provider, there are 18 payers. For every 5 payer applications, 25 working hours of the hospital staff and physicians are consumed. Also, approximately 85% of the applications still need to be completed. (Shah, 2023) Figure 2.  Basic Credentialing Facts Challenges in the Credentialing Process Incomplete or Inaccurate Documentation Incomplete or inaccurate documentation is a common challenge in the credentialing process. Thoroughly reviewing the application materials and seeking assistance, if needed, can help mitigate this challenge. Maintain clear records of all documentation submitted and maintain copies for reference and future updates. Insufficient Qualifications Meeting specific qualifications, such as experience, licenses, certifications, or exam scores, is crucial for successful credentialing. Regularly reviewing and updating qualifications, participating in continuing education, and seeking professional development opportunities help providers stay current and fulfill credentialing requirements. Lack of Adherence to Credentialing Standards Adhering to credentialing standards is essential for a smooth credentialing process. Familiarize themselves with the specific standards and ensure they comply with professional conduct, ethical behavior, and patient safety requirements. Regularly reviewing the credentialing standards and seeking ongoing education on changes or updates to these standards promote ongoing compliance and avoid potential challenges. Inadequate Professional References Successful credentialing requires credible professional references highlighting the provider’s skills, knowledge, and abilities. Establish professional relationships and seek references from respected individuals who can vouch for their qualifications and competence. Engage in professional networks to facilitate the collection of robust references. Disciplinary Actions or Malpractice History Providers with a history of disciplinary actions or malpractice may face challenges during credentialing. Credentialing organizations are concerned about the provider’s competence and safety. Prepare to address any disciplinary or malpractice history concerns and provide explanations or evidence of corrective actions. Seeking legal counsel or assistance from credentialing experts can help providers navigate these challenges effectively. (Shah, 2023b) Common Documents and Information Required for Credentialing Applications Typically, credentialing applications include: 1. Educational Background and Training Documentation: Healthcare providers must submit comprehensive documentation that validates their educational background and training. This includes transcripts, diplomas, degrees, and records of specialized training, fellowships, and continuing education courses. Accuracy in these documents is crucial as they reflect the provider’s expertise in their specific field of practice. 2. Licensure and Certification Details: Credentialing applications typically seek information about the provider’s current and past licensure status. This encompasses their medical license, board certifications, and any history of disciplinary actions or license restrictions. 3. Malpractice History and Insurance Coverage: Disclosure of malpractice history, including any claims, settlements, or judgments, is standard procedure in credentialing applications. This information helps assess the provider’s risk profile and ability to deliver safe, high-quality care. Providers must also furnish proof of malpractice insurance coverage or alternative means of financial responsibility. 4. Professional References and Recommendations: Credentialing applications often require professional references from colleagues, supervisors, or others familiar with the provider’s clinical practice. These references offer insights into the provider’s professional conduct, clinical skills, and teamwork abilities. Recommendations from respected professionals carry significant weight in the credentialing process and positively impact the provider’s application. 5. Practitioner Data Bank and National Provider Identifier (NPI) Registration: Providers are obliged to disclose any adverse actions or reportable events as required by the National Practitioner Data Bank (NPDB). This includes malpractice settlements, disciplinary actions, or exclusions from federal healthcare programs. Additionally, providers must obtain a National Provider Identifier (NPI) and include it in their credentialing application. The NPI standardizes

People handle adversity differently; some break down sooner than others. When a team focused on a common goal faces adverse conditions, dissent among some team members precludes them from reaching a shared goal. Under extreme conditions, a mutiny isn’t just mission-critical—it can leave everybody dead. The famous explorer Ernest Shackleton, best remembered for his Antarctic expedition of 1914–1916 in the ship Endurance, managed such risks by assigning the whiny, complaining crew members to sleep in his own tent and share the chores with him. Clustering the “complainers” with him minimized their negative influence on others, and this helped his team survive and accomplish their goals. Medicare Vs. Private Payers It’s essential to acknowledge the contrasting dynamics between Medicare and private payers. Medicare, as a government-backed program, follows distinct regulations and reimbursement structures, while private payers operate in a competitive market with more flexible terms. The negotiation strategies and considerations may differ significantly when dealing with these two payer types. Payment negotiations Actively negotiating with payers is crucial for independent medical practices. However, many providers lack experience or haven’t been successful in past negotiations due to inadequate preparation. To ensure a fruitful negotiation, it’s vital to: Know Your Data: Understand your practice-specific data, including patient volume, charges, reimbursement history, and more. Know the Terms of Each Contract: Familiarize yourself with your current payer-specific contract terms, especially the reimbursement schedule and the claims filing data. (Babcock, 2021) According to a KFF analysis, as seen in the image below, private insurers often pay nearly double the Medicare rates for hospital services. Specifically, for outpatient hospital services, private insurance rates were found to be significantly higher than Medicare rates, averaging 264% of the latter. This difference underscores the varying dynamics and market powers between Medicare and private insurers. Policymakers and analysts continue to debate the necessity of high payments from private payers to compensate for the lower Medicare payments. (How Much More Than Medicare Do Private Insurers Pay? A Review of the Literature | KFF, 2020) Classification of Payment Models Payment models dictate how healthcare providers, including physicians and hospitals, are remunerated for their services. Each model inherently carries incentives and disincentives that can influence the balance between cost reduction and improving care quality. These two objectives often stand at odds. This report delves into the implications of Alternative Payment Models (APMs) in either mitigating or intensifying health disparities. However, before exploring these implications, it’s essential to understand the incentives and disincentives embedded within the prevailing payment models. These incentives play a pivotal role in fostering cost-efficient, high-quality care. The primary distinction among these payment methods lies in the unit of payment. This determines how financial risk is distributed between the payer and the provider. The nature of this risk can significantly influence the behavior of healthcare providers and the overall efficiency and effectiveness of the healthcare system (Quinn, 2015). Factors affecting payment negotiations According to AMA, it’s not just about the rates but also about the terms and conditions that can impact payment. For instance, some contracts might have clauses that allow payers to change rates without notice, or they might have stringent requirements for prior authorizations. Providers should be wary of “most favored nation” clauses, which can restrict them from offering better rates to other payers. It’s also crucial to be aware of the dispute resolution process outlined in the contract, should any disagreements arise. By being well-prepared and understanding the intricacies of payer contracts, providers can position themselves for more favorable negotiations and better financial outcomes. (American Medical Association & American Medical Association, 2022) Payer-provider conflict In the payer-provider conflict, the providers who accept lower reimbursement and who don’t challenge underpayments or delayed payments make it easier for the payers to maintain their market control (oligopsony). Recent research supports this notion, indicating that payers with larger market shares have more negotiating power in contract negotiations (HealthPayer Intelligence). ClinicMind’s network helps providers maintain their payment schedules and motivation by establishing a shared discipline for clients and billers alike in terms of both thought and action. Payers with Larger Market Share and Their Negotiating Power Payers that have a dominant presence in the local market have a distinct advantage when it comes to negotiating lower prices for physician office visits. A study conducted by researchers from Harvard Medical School found that health insurance companies with a market share of 15% or more negotiated visit prices that were 21% lower than those set by payers with a market share of 5% or less. For instance, payers with less than 5% of the market negotiated prices of $88 per office visit. In contrast, those with 5 to 15% of the market share settled for a price of $72, and those with more than 15% of the market share negotiated even lower at $70 per visit. The graph below shows this analysis.   From Policy Changes to Physician Consolidation In 2010, President Barack Obama signed the Affordable Care Act (ACA) into law, a move that expanded Medicare’s reach by adding millions to its coverage. This expansion meant that more physicians had to accept Medicare rates, which have been systematically reduced over time. The ACA not only aimed to extend healthcare access to uninsured Americans but also set in motion a wave of consolidation in healthcare services. As Medicare adjusted its rates, private insurance companies followed suit. While they still paid above Medicare rates, they too began to reduce their payouts. This trend forced physicians to grapple with a challenging reality: working more hours for less pay. The Power of the Network Effect In response to these financial pressures, physicians began to see the value in consolidating their practices. By joining larger organizations, they could harness the network effect, gaining more significant negotiating leverage with insurance companies. This consolidation is not just about survival; it’s about strength in numbers. Large groups, especially those with revenues exceeding $1 million annually, have more room to negotiate than smaller entities. The Rise of Management Service Organizations (MSO) Amidst these challenges,

In the last chapter we talked about hunger and the drive that must exist between all members of a patient community, including the patients themselves, but what about the patient’s need for a mentor? Remember in previous chapters we talked about how Joseph and Bonnie’s dispositions not only affected their ability to treat effectively but also resulted in lost patients? Patients, because they are people, respond and react to the emotions they receive. We don’t always react in the expected way, but that has more to do with the person interpreting than the person reacting. So how do we set ourselves up so that when we aren’t having the best day ever and performing at our peak state, our patients still receive the best care possible? The answer is heroism. And no, I’m not talking about superhero heroism like we see in the movies today. I’m talking about the heroism of someone behaving in a consistent and positive way that inspires others. When people see someone working harder than everyone else (and I don’t mean slightly harder, I mean orders of magnitude harder), they naturally want to help that person. Following success is a tremendous motivator for many because it means that they don’t have to expect 100% effort from themselves to achieve a goal. In other words, the responsibility isn’t 100% on them, and so they feel compelled to work as hard as possible, if not harder. We all know the power of heroes in fiction and how they inspire their comrades and even enemies, in many cases, to follow the path of good and righteousness. Take the most famous superhero of them all. Superman. As we prepare for the dawn of the Superman movies in cinema, these films raise powerful questions about what is meant by a leader. Many would say that Superman is an example of a great hero, but I would disagree. Superman is a great character and, in fiction, does amazing things for many. However, because his power is so great and far removed from our own, we don’t feel like what he does is ever enough (hence people never truly appreciate Superman except when their lives are on the line). As practice owners and clinicians, we’re often seen this way. We hold in our minds and hands, the ability to create massive change in a patient’s life, change that that patient would otherwise be unable to experience. This truly defines us as Superheroes, but it also presents a major problem. It means we are too far removed from our patients resulting in this kind of detached relegation. We feel compelled as patients to receive care and do so reluctantly, hoping we never need to return (think about it, how many patients truly want to be thinking about their illness?). Now take the example of the practice owner and how we react when we feel like superheroes. Sure, at the beginning, it’s an incredible ego booster, it makes us feel like we are kings and invincible. But then what? The feeling goes away, and we’re left with a patient roster that, quite frankly, is embarrassing by superhero standards. Naturally, this gives way to the feeling of inadequacy and negativity we discussed earlier. So what do we need to do? Simple (but not easy), we need to get closer to our patients. In other words, we need to close as much of the rift between a patient and their physician as possible. Since this is a natural phenomenon with man-made side effects, it is especially difficult to resolve. It means that we, as practice owners, have to first overcome our confidence needs to see ourselves as our patients see each other, powerful and capable. Above is a diagram that describes what I’m talking about. Nature develops these build-in separations as we grow in expertise and capability, but it also creates a lack of empathy and connection with our patients. The real question is, who is responsible for bridging this gap? Heroism lies in effective communication with patients and addressing their concerns holistically. As a practitioner, you should be able to listen to, understand, and share in people’s feelings, beliefs and experiences in order to take care of their real needs and offer individualized care rather than just focusing on the science of the illness. This is part of the spectrum of empathetic communication (Moudatsou et al, 2020). Several strategies can be used to effectively communicate with patients. These include active listening, using plain language while avoiding technical jargon, using relatable examples and illustrations, using appropriate language, keeping the interaction confidential and letting patients explain concepts in their own words to demonstrate understanding. (Tulane University School of Public Health and Tropical Medicine. Strategies for Effective Communication in Health Care. Sept 2021; Float Care 2023 ) Here’s a great personal example. In graduate school, I was a teacher’s assistant (professor lackeys or TAs as we were widely known) teaching the recitation for a course on statistics for Psychology undergraduate majors. These were first-year students who, for the most part, had no idea what they were doing, but also knew exactly what they were doing. As with most young people, there was a split, and although they needed guidance, they weren’t ready to admit it yet. This was clear in the first month as I clearly entered the room as an authority figure. I was confident in my knowledge of the material and ability to convey it in a manner that would instruct students (sounds engaging, doesn’t it?). Obviously, you can imagine what happened next: I inspired exactly zero students to actually be interested in the material and as a result, many did not pass the first exam. There was an uproar from the professor and from the students, apparently thinking that the recitations were the source of the problem. The professor sat me down for an hour over coffee and tea (I was the difficult one who didn’t and still doesn’t drink coffee), explaining the difference between

Great, now Reuven wants to know if I’m hungry. Don’t worry, we’re not talking about hunger pains or anything like that. I’m talking about drive, the hunger to stop at nothing to succeed. But I’m also not talking about it in the most general sense. In other words, we’re not talking about all those Youtube videos dealing with motivation, drive, and hunger. I’m talking about the hunger unique to healthcare that is required to create a thriving practice. I’m talking about community hunger. When you want to put together a thriving patient community, regardless of specialty, of course, it’s critical that both you, your staff, and your patients feel a certain hunger. Gone are the days of thriving practices where patients simply receive care. Today, a thriving practice depends on the teamwork built between a patient and the staff in the office. However, anytime you have a team, you need teamwork based on a voracious hunger. A driving force that unites the team and propels them forward. Clearing objectives, roles, and expectations; providing training and support; promoting diversity and representation; providing incentives and feedback; and securing institutional support and sponsorship are all examples of effective patient engagement tactics, according to a systematic review on the topic published in Bombard et al. (2018). One of the biggest misconceptions about hunger and drive is that you must be an extrovert or high-energy person to derive strength from hunger truly. In fact, I’ve quite often experienced the opposite. In Joseph and Bonnie’s case, these two had opposing personalities, but Bonnie, who was more of an introvert than Joseph’s incredible extroversion, was clearly overcome by a stronger hunger. She was more consistent in her behavior and suffered from less burnout than Joseph. She was also more adaptable. She was able to empathize with both high-energy patients and low-energy ones. Experience really is the best teacher, and more often, it’s easier to understand high-energy people from a low-energy perspective than to understand low-energy people from a high-energy perspective. According to research, personality factors have been linked to job satisfaction and burnout among healthcare professionals. For instance, higher neuroticism levels have been associated with lower job satisfaction, increased emotional exhaustion, and depersonalization. Contrarily, agreeability and scrupulosity are positively connected with job satisfaction and adversely associated with depersonalization (Kang & Malvaso, 2023). These findings imply that managing burnout and enhancing worker well-being in healthcare settings can be facilitated by understanding various personality types. I’ll give you a personal example. I am a high-energy person who loves to be loud, talk fast, and get from A to B with as little in between as possible. I was always the quintessential type A personality who never enjoyed the journey because he was too caught up in achieving the destination. In school, that can often do well for you, as I always achieved top scores on exams and papers. However, my personal relationships suffered greatly. For example, I could never maintain quality friendships (although I had many friends), and forget about romantic relationships where you truly need to be present to be successful. Imagine being so caught up in the result of effort and bringing that to a romantic situation. Strong leadership is crucial in community-based healthcare practices. Effective community involvement projects have been shown to involve communities in planning, designing, implementing, and evaluating primary health care services. Community leaders are essential in promoting teamwork and driving the group toward shared objectives (Erku et al., 2023). Ultimately, I had to recognize the drawbacks of my personality and the opportunities that presented. In other words, what were the challenges I had to overcome, and how would those help me to become a better and more contributing individual? At the same time, I struggled because some of my friends had great connections, and I often felt that they were lazy because they spoke slower, didn’t engage at a super high level of energy, and often stayed home instead of constantly going out. It’s important to consider the varied personality types’ needs for recharge time (Grailey et al., 2023). Now we understand the difference in recharge time required for different personality types. For example, if you are more introverted, you can definitely be the life of the party, but afterward, you’ll need some time to recharge the batteries. There’s nothing wrong with this; in retrospect, I think this is more beneficial than constantly being out. The literature also emphasizes the importance of reflection and self-awareness in identifying one’s fundamental limitations and comprehending the advantages associated with various personality characteristics. Extroverts may thrive in social situations and get their energy from continual engagement, but introverts have a special ability to use deep thought and reflection to advance both personally and professionally. This implies that accepting and comprehending one’s innate characteristics might result in personal growth and achievement in a variety of areas of life (Grailey et al., 2023). It challenges us to search for that hunger within instead of constantly being hungry for what’s outside of us. In my personal struggle to expand beyond my core limitations, I recognized the incredible power of introverted people and how I could leverage that to grow personally and professionally. However, one of the biggest mistakes people make is thinking they can grow this way independently. In other words, they think there is a way for them to simply absorb this information without help. Nothing could be further from the truth. Studies have underlined the value of mentoring for improving patient outcomes, career growth, and skills in healthcare settings (Nandwani, 2023). The analogy of hunger shows how, similar to the body’s requirement for nutrition from outside sources, people may need coaching to comprehend and successfully realize their inner desires. Without the right direction, they could make detrimental decisions repeatedly, just like when they consume “junk” without understanding their genuine needs. Mentorship serves as a compass, assisting people in discovering their true desires and fostering both personal and professional development. Think about your body, your purest form of

Medical billing complexity and massive volumes of daily claims render manual claims processes incapable of protecting both the provider and the payer from underpayments, overpayments, and billing compliance violations. Straight-Through Billing (STB) addresses complexity and volume processing problems by automating the majority of the claim flow and focusing the billing follow-up specialists on exceptions only. An STB process flags problems, routes them for follow-up, and enables online correction and resubmission. The STB methodology implements billing service transparency and focuses management on strategic process improvement opportunities.  Straight-Through Billing integrates the billing process into the practice management workflow, automates the vast majority of transactions, focuses manual labor on exceptions, and establishes a process for continuous improvement.   Remember:  Straight-Through Billing offers a comprehensive approach to improving the billing process, integrating various components, and promoting continuous improvement.    Practice Management Integration  First, integrated practice management and billing workflow connects patient scheduling, medical record management, and billing into a single process. Every participant in the practice  management workflow receives a unified and coherent picture of the practice workload, patient and provider location, resource availability, and cash flow. However, integrated with Electronic Health Records, practice management systems are more beneficial. Electronic health records (EHR) are digital formats of a patient’s chart. They contain all the information about a patient’s health. This includes medical history, allergies, immunizations, previous treatments, medication history, past diagnoses, history of substance abuse (if any), and so forth (Shah, 2021).    Transaction Automation   Transaction automation streamlines and expedites the billing process by automating claim validation, payer message reconciliation, and billing workflow management:   Automated claim validation eliminates errors downstream and reduces processing time because it flags errors before submitting the claim to the payer.   Automated claim message reconciliation eliminates the costly search for the original claim and standardizes message communication, eliminating the need to decipher the (often cryptic) payer’s message.   Automated billing workflow management drives the follow-up discipline required for the resolution of claim denial and underpayment incidents, and it establishes a high degree of process transparency for all billing process participants, resulting in full and timely payments.   Automated billing increases the net collection rate due to quick claim turnaround and efficient follow-up. Respond to your denials within 5-21 business days of receiving them, using our Daily Denial Email Alerts (Qureshi, 2022).   Focus on Exceptions   Focusing manual labor on exceptions requires timely exception identification, routing to follow-up personnel, online error correction, and rigorous follow-up tracking. Again, process transparency enables tracking exception follow-up as implemented in ClinicMind-like systems. Another significant benefit of automated medical billing is the ability to track and analyze financial data. With this, healthcare facilities can monitor their revenue cycles, identify growth opportunities, and generate detailed financial reports (Polo, 2023).   Continuous Process Improvement   Finally, a process for continuous improvement requires continuous observability of every process attribute and a modification methodology for both automated claim processing and manual exception follow-up tracking.  Straight-Through Billing implements billing transparency by design because billing transparency is an integral attribute of every component of the STB process.  It also enables businesses to streamline their billing operations, reduce errors, enhance efficiencies, and improve the customer experience (Ward, 2023).    Straight-Through Billing Architecture    The Straight-Through Billing systems architecture mirrors the architecture of general Straight-Through Processing (STP) systems developed for the financial services industry. Such systems require effective workflow management, a knowledge-based validation system, connectivity to all process participants (including online data reconciliation), and tracking of problem resolution. Therefore, a typical ClinicMind-like STB system has a three-tiered architecture:   Back-end processing engine, designed for a high-volume transaction processing environment   Middle tier, using Java Servlet technology   Front end, using an HTML-JavaScript, zero-footprint client     Did You Know?  The STB architecture is inspired by the systems used in the financial services industry, showcasing the transferability of advanced processing concepts across different domains.    An STB system (e.g., ClinicMind) based on the methodology outlined here implements rich functionality, which allows the following to be automated:   Computer-aided preferential patient scheduling   Integrated electronic medical records   Online computer-aided coding   Real-time claim validation and patient eligibility testing   Electronic claim submission   Payment posting, reconciliation, and verification of meeting contractual obligations   Monitoring of audit risk and billing compliance   Tracking of denial appeal process     Quantitative STB Management    Straight-Through Billing methodology allows for quantitative management since the likelihood of the entire process failing can be estimated as the product of such items for each individual workflow step. A ClinicMind-like STB system tracks the percentage of clean claims (claims paid in full, and within the allocated time frame, without any manual intervention) and focuses the management on those process aspects that yield the greatest potential improvement. Thus, STB methodology focuses on exceptions at both the tactical and strategic management levels and can help to improve cash flow and reduce outstanding invoices by providing real-time visibility into billing and payment status (Mielnicki, 2022).    Modern Insights and Research In the ever-evolving field of medical billing, staying ahead of the curve is crucial for achieving financial excellence in the healthcare industry. Let’s embark on an exhilarating journey into the future of medical billing, where the convergence of electronic health records (EHRs), artificial intelligence (AI), real-time analytics, and collaborative efforts reshapes the revenue cycle landscape. Brace yourself for a transformative exploration that revolutionizes processes, enhances data accuracy, maximizes financial outcomes, and ushers in an era of unparalleled efficiency and effectiveness in the dynamic realm of medical billing.  Role of Blockchain Technology in Billing Systems The seamless integration of electronic health records (EHRs) and billing systems is revolutionizing the field of medical billing. Gone are the days of fragmented medical records scattered across various healthcare organizations. With blockchain at the helm, a distributed EHR ecosystem emerges, ensuring a smooth flow of information between providers. By eliminating manual data entry and ensuring accurate documentation, this innovative technology guarantees accurate and secure documentation, eliminating errors and speeding up reimbursement processes (Cerchione et al., 2022). But that’s not all. Blockchain brings an unparalleled level of data integrity and security, employing cryptographic techniques to safeguard

AI has revolutionized many different industries, and healthcare is no exception. In recent years, medical billing has benefited greatly from using Artificial Intelligence.   Where are the major pain points in healthcare today? 1-Patients:  A major challenge today is long wait times. In 2022, the average wait time for a physician appointment in the 15 largest U.S. metro markets is 26 days [1]. The longer someone has to wait, the higher the risk of complications or possibly more serious health issues arising.   Some possible solutions to address this problem include  use of telemedicine involves providing medical consultations and services remotely using technology such as video conferencing.   increasing the number of healthcare professionals in practice,  streamlining administrative processes and  improving patient communication and education to help prevent avoidable illnesses and hospital visits.   2-Physicians:  Physician burnout is affecting a high percentage of physicians. 62.8% of physicians experienced at least one symptom of burnout in 2021 [2]. Reasons for burnout include outdated technology and inefficient workflows, which contribute to increased work stress and frustration even for skilled and experienced professionals. Additionally, a shortage of skilled workers puts extra pressure on those in the workforce, leading to burnout and poor job satisfaction. One potential way to address these challenges is to invest in updating technology and improving workflows, which can streamline processes and reduce workload. Additionally, increasing access to training and education for both current and future workers could help alleviate the skill shortage issue. It’s essential to take proactive steps to address these issues to ensure that our healthcare workforce can continue to provide top-quality care to patients without experiencing burnout.   3-Payers:  Payers recognize the importance of delivering better experiences to their customers. To meet these expectations, payers are focusing on several critical areas:  A-Improving ease of use  Improving ease of use can be achieved through various initiatives, such as clear communication to help customers understand their network, status updates on claims, and easy-to-use portals and tools.   B-Ensuring the availability of services on-demand.  Having around-the-clock access to support and information is essential to ensuring customers can get the help they need when they need it.  To support these initiatives, payers need to leverage data-driven insights to create value for their customers. This can be achieved through technologies such as artificial intelligence and machine learning, which can help to identify trends and patterns in customer behavior and preferences, enabling payers to provide targeted and personalized support proactively.  Overall, payers must continue to innovate and adapt to meet the evolving needs and expectations of their customers, and taking a data-driven approach to improve ease of use and availability on demand could be a critical step forward. C-Reducing hospital readmission rates   Payers are leveraging machine learning to gain actionable insights from healthcare data sets. By analyzing claims data, payers can identify trends in patient outcomes and determine the most effective treatments for specific patient populations. They can also predict which patients are at a higher risk of complications or readmissions, e.g., inflammation and blood clotting occurs most following surgery, and provide this information to providers to help them take preventative measures. This kind of data-driven approach is valuable because it enables healthcare providers to deliver more personalized care to patients, leading to improved patient outcomes and reduced costs. By sharing these insights, payers can demonstrate the value of their contributions to patient care while simultaneously empowering providers to make better decisions and improve healthcare delivery.   Improved Medical Coding Accuracy One way AI has been used in medical billing is through automated billing and coding. The technology can analyze electronic health records and notes made by healthcare providers and use that information to generate codes that accurately bill for specific services. This reduces the risk of errors, which can result in denied claims and lost revenue.   Improved Insurance Cash Flow Prediction and Denial Management  AI is also used for claims prediction. By analyzing past claims data, AI identifies patterns and predicts which claims will likely be denied. This allows billing teams to proactively address issues and avoid denials, which saves time and money.   Also, when denials are increasing due to a lack of medical necessity, lacking documentation, or coding mistakes, AI can analyze the denials to find the cause and then create tasks within the EHR to correct the likely causes for denials.   Improved Medical Billing Workflow To automate the claims follow-up process, AI analyzes claims data and identifies the claims that are most likely to require follow-up.  AI automatically generates follow-up tasks for billing teams. This reduces the administrative burden on billing teams and ensures that claims are followed up on in a timely manner. The deep learning of users’ interaction with EHR and billing software allows the learning of users’ habits, needs anticipation, and the display of the right data at the right time. Automatically retrieving and displaying all of the required data and just at the right time drastically reduces the amount of labor spent on manual billing tasks and allows staff to make better decisions about the next steps for denial resolution.   Improved and Expedited Pre-Authorizations The current pre-authorization process can be a real headache for patients and healthcare providers. A streamlined, automated system that can quickly analyze a patient’s health data and determine the medical necessity of a procedure would be a game changer. Imagine how much time, stress, and resources could be saved if medical billers no longer had to worry about pre-authorization denials or chasing down authorization numbers. It’s exciting to think about how technology can continue to improve and simplify healthcare processes like this.   Improved patient customer service With the rise of technology, we’re seeing a lot of improvements in healthcare that can benefit patients and providers alike. Using bots for patient interactions like appointment scheduling and payment collection is one way to streamline processes and reduce frustration for patients and billing staff. By standardizing these tasks, there’s less room for error and confusion, leading to smoother, more efficient

Partial denials cause the average medical practice to lose as much as 11% of its revenue (Capko, 2009).  Payers are known for denying claim payments for legitimate reasons (provider-generated errors) and arbitrary reasons, motivated by the inherent benefits of controlling the float for the maximal time (Stahl). Systematic denial management must address both kinds of errors.  Denial management is difficult because of the (intentional) complexity of denial causes, payer variety, and claim volume.  Systematic denial management requires measurement, early claim validation, comprehensive monitoring, and customized tracking of the appeals process. According to a survey by the Medical Group Management Association (MGMA), 69% of organizations reported a significant increase in denials, averaging 17%, in 2021 alone. These findings are further supported by additional alarming statistics  (Zipple, 2023):   In 2021, claim denials surpassed 48 million (Kaiser 2023). On average, nearly 20% of all claims are denied, and shockingly, up to 60% of these denied claims are never resubmitted (Poland and Harihara, 2022) Certain payers exhibit denial rates as high as 80% (Revenue Cycle Intelligence, 2022)   However, there is some hope as, on average, approximately 40% of denials can be overturned through appropriate appeals processes (Kaiser 2023). According to a HIMSS Analytics study, here are some key findings on how hospital executives manage claim denials:  44% of hospital executives rely on vendor solutions to manage denials. 31% of executives still handle denials manually, without any specific tool or software. 18% of hospitals have developed their own in-house tools for denial management. 7% of executives are unsure about the method they use for denial management. Among respondents without a vendor-provided solution, 60% plan to purchase one within the next 7-12 months. (Regulsky, 2023)   Denial Risk Classification The denial risk is not uniform across all claims. Certain classes of claims run significantly higher denial risks, depending on six factors: Claim complexity  Modifiers, e.g., incorrect modifier used  Multiple line items Temporary constraints Claim not filed on time   Patient constraints, e.g., claim submission during global periods (see below) Payer constraint (e.g., claim submission timing proximity to the start of the fiscal year) Procedure constraint (e.g., experimental services) Payer idiosyncrasies Bundled services, e.g., services incorrectly bundled or Unbundling and upcoding  Disputed medical necessity, e.g., Not a medical necessity   Non-covered services   Other Patient data Patient deductible   Plan benefits exhausted   Provider data, e.g., Out-of-network (OON) provider   Process Compliance Incorrect insurance ID number   Duplicate claim submitted   Prior authorization not attached   Typo errors in patient information   Note that for complex claims, most payers pay the full amount for one line item but then pay only a percentage of the remaining items. This payment approach creates two opportunities for underpayment: The order of paid items The payment percentage of the remaining items   Next, temporary constraints often cause payment errors because of the misapplication of constraints. For instance, claims submitted during the global period for services unrelated to the global period are often denied. A global period is a period of time before and after a surgical procedure during which related services are bundled into the initial procedure’s payment. It helps streamline billing by including pre-operative visits, post-operative follow-up care, and related services within a single payment (Master, 2020). Similar mistakes may occur at the start of the fiscal year due to misapplying rules for deductibles or outdated fee schedules. Additionally, payers often vary in their interpretations of Correct Coding Initiative (CCI) bundling rules or coverage of certain services. Developing sensitivity to such idiosyncrasies is a key to full and timely payments. CMS contractors conduct medical reviews on certain claims and prior authorizations to ensure that Medicare payments are made only for services that comply with all Medicare regulations. Suppose a review leads to a denial or non-affirmation decision. In that case, the contractor responsible for the review provides the provider or supplier with a comprehensive explanation detailing the reasons for the denial or non-affirmation.  For example, the code AM300 is used when the provided documentation lacks evidence to substantiate the provision of Basic Life Support services during an emergency response. Please refer to 42 CFR § 410.40 (c), 42 CFR § 414.605, Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 20, and Section 30.1.1 for further clarification and guidelines on this matter. (Reason Statements and Document (EMDR) Codes | CMS). Payers can also separate the Claim Processing and Denial Management departments to add complexity and improve the likelihood of underpayments and delays. In this scenario, the provider may be forced into a deadlock by having to deal with two separate departments for the same claim, where each of the two departments “waits” for the decision of the other.   Denial Risk Management Stages In a high-volume clinic, the only practical way to manage denials is to use computer technology and follow a four-step procedure:   1. Prevent mistakes during claim submission    This can be accomplished with a built-in claim validation procedure that includes payer-specific tests and EHR integration. Such tests (“pre-submission scrubbing”) compare every claim with Correct Coding Initiative (CCI) regulations, diligently review modifiers used to differentiate between procedures on the same claim, and compare the charged amount with the allowed amount, according to previous experience or the previous contract, to avoid undercharging.   Integrating EHR and claims management systems allows for the seamless transfer of patient data and encounter information from the EHR to the claims system. This eliminates the need for manual data entry or transcription, reducing the chances of errors or omissions that may occur during the claims submission process.  EHR systems often include built-in templates and structured documentation features that guide providers to capture complete and accurate information. These templates help ensure that all necessary information for claims submission, such as procedure details, diagnoses, and supporting documentation, is appropriately recorded.   2. Identify underpayments   Identifying underpayments in the claims process is crucial for healthcare organizations to ensure accurate reimbursement and maximize revenue. This involves comparing the payment with the allowed amount, identifying zero-paid items, and evaluating payment timeliness. The

Without a computerized scheduler, a practice has less than a 2% chance of earning the title of a “better-performing practice,” according to the Medical Group Management Association. Computerized scheduling helps decrease service costs, provide fairness in service delivery, increase patient satisfaction, and reduce waiting times (Zhang et al., 2019). A massive investment in scheduling features across a wide spectrum of billing products indicates the importance of computerized scheduling. Convenience and front office efficiencies are two obvious benefits of a computerized scheduling system; without them, the only manual way to find out if a specific patient has a scheduled appointment is to flip through the appointment book page by page. Worse, manual scheduling hurts both patient satisfaction and practice financial performance because of scheduling inconsistencies and unbilled (and therefore unpaid) visits. But the benefits of integrated computerized scheduling stretch far beyond convenience, front office efficiencies, and better charge follow-up of stand-alone, albeit computerized, scheduling. A well-designed and integrated scheduler allows preferential patient scheduling, which, along with improved controls, helps revenue optimization and practice compliance. Next, we review key aspects of computerized scheduling and demonstrate the important benefits of integrated scheduling, billing, and compliance management. Scheduling Policies Computerized schedulers allow a combination of single- or multiple-interval scheduling, with open-access scheduling subject to various priority constraints. Such priority-constraint-driven, open-access scheduling creates preferential appointments based on patient demographics or insurance coverage. Typical time-slot-based appointment systems essentially divide a physician’s schedule into finite slots in a day, which can be allocated according to appointment requests. However, such systems are limited by the risks of schedule fragmentations in late shows or no-shows (Chen et al., 2019). Examples of time-slots-based scheduling include single-interval scheduling and multiple-interval scheduling. Single-interval scheduling allocates appointments at regular intervals of 5 to 15 minutes, depending on the specialty. The downside of single-interval scheduling is that as soon as one appointment takes longer than the allocated slot, all subsequent patients must wait. Multiple-interval scheduling also sets appointments at regular intervals; however, unlike single-interval scheduling, it allocates the appointment length depending on the chief complaint. Such scheduling requires up-front categorization of key appointment types and their projected lengths. For instance, an initial appointment might take 30 minutes, while a routine injection might take only 5 minutes. According to the CAHPS survey database, about 12% of patients who called in did not get appointments for urgent care that they needed at the time. Forjuo et al., (2001) also showed that inadequate access to primary care providers was a leading cause of patient dissatisfaction. These challenges are mitigated by open-access scheduling. Open-access scheduling requires holding several appointments open every day. These open appointments are filled only within 48 hours of the appointment, catering to same-day or last-minute patient requests. Open-access scheduling improves access to the physician, reduces no-shows, and eliminates patient screening time. The downside of open-access scheduling is, of course, the potential for longer patient waiting lines or physician idle time because of the inability to maintain a predictable patient flow. A novel scheduling variant is the overlapping appointment scheduling (OLAS) model (Huet et al., 2020). OLAS model refers to deciding the optimal overlapping periods between the patient appointment and allocated service times. The model is formulated as an optimization problem to minimize the total cost of patients waiting and doctors’ idle time. One way to balance the practice workload is to schedule group, routine, or repeat appointments during slow hours. For instance, pediatric well-child visits or patients with a particular chronic disease—such as congestive heart failure or diabetes—could be scheduled for early mornings when there are typically fewer patients waiting in line. These scheduled visits include educational components and often involve multidisciplinary teams. It also helps save time since standard advice need not be repeated to individuals, improving on the efficiency of care delivery (Jones et al., 2019). Patients also benefit from the socialization aspect of group visits; members encourage one another, exercise together, and so forth. A good scheduler allows a repeat appointment schedule subject to total frequency and time slot constraints. Compliance Process An integrated scheduler verifies the filing of a signed patient consent form—and, in certain cases, a signed ABN form. An ABN (Advance Beneficiary Notice) serves three goals: To protect the beneficiaries from liability for services denied as not reasonable (depends on the frequency or duration) and necessary (depends on the diagnosis and the provider’s specialty) To protect the provider’s revenue by shifting financial liability for denied services to the patient To provide documentation for a Medicare audit   For more complex procedures, the scheduler warns the front office about the need to obtain all required diagnostic test results and clearances up front. Billing Interface The integrated scheduler avoids unbillable patient encounters and reconciles visits with patient balances. It checks outstanding patient balances and verifies coverage and eligibility at the point of scheduling before the appointment. AI-driven computerized coding and billing systems can accurately provide the code for a particular disease condition and help with appropriate automated billing (Venkatesh et al., 2023). In many cases, such a test discovers data entry errors too, reducing the payment cycle at later stages. Additionally, the insurance company may require referrals or separate pre-authorization/certification for certain procedures, refusing the payment if the procedure was performed without a referral or preauthorization. The integrated scheduler can access medical records to supply necessary background and diagnosis information to obtain pre-authorization. Finally, without the ability to reconcile visits with payments, the practice owner cannot be sure that every visit resulted in a payment. Practice Flow Interface The integrated scheduler manages the entire patient flow, continuously updating arrival lists, checkoffs, and office/room tracking. Further, the scheduler tracks no-shows and follow-up actions. Detailed reports include daily schedules, load reports, missed appointments, free time, canceled appointments, etc. With AI-integrated schedulers, different color codes and status flags can be used for different appointment types, whether emergencies or routine or based on the specialist to be seen by the patient. This offers a good visually appealing summary by just glancing over the

I love this topic because it’s easy to miss the mark, especially since so many consultants and marketing firms misappropriate this term and don’t actually coach on value-adding. The idea of value-adding has come under scrutiny in light of the current trend of corporate acquisitions of primary care clinics and the rising patient expectation for comprehensive, patient-centered treatment (Abelson, 2023). This is because of how the healthcare industry is changing. There is a growing need to separate actual value addition from empty rhetoric when corporate companies acquire primary care operations. The demand for genuine, efficient value-adding solutions has never been greater due to the rise in patient expectations for a comprehensive healthcare experience. Don’t get me wrong, plenty do an absolutely amazing job, and their clients see great results, but more often than not, disaster strikes. Especially in the case of Joseph and Bonnie… When Joseph and Bonnie opened their practice, they were die-hard, convinced that they only needed to practice their specialty and nothing else. If we stay true to our specialty’s expertise and principles, we shouldn’t need anything else in the practice to thrive. Although reasonable, this viewpoint failed to consider the changing expectations of healthcare consumers. Patients are increasingly looking for holistic healthcare that covers their current requirements and their long-term well-being, according to Yussof et al. (2022). This suggests Joseph and Bonnie’s single-focused strategy didn’t meet the patient’s desire for comprehensive care. Today’s patients want treatments that address their current health needs and promote wellness, including preventative and long-term health management. Thus, healthcare professionals who offer more services are valued more. So they went about building out a space with the money their mentor had given them and whatever they could find and were adamant that physical therapy was the only service to be offered. Once the space was open, they began marketing to orthopedists in the area and getting patient referrals. That’s when the opportunities opened up. Patients started asking about ancillary services they didn’t have, making them feel like they looked silly. Patients asked about home fitness programs, nutrition, supplementation, and other specialties like Chiropractic or group fitness. The study by Patel & Singhal (2023) demonstrates the growing tendency of patients to seek comprehensive care. It showed that most patients favor healthcare facilities that offer various services under one roof. Patients increasingly view healthcare as a holistic activity. They want nutrition advice, exercise regimens, and alternative cures, not just specialist therapy. This shift in patient preferences fuels the desire for multi-service healthcare facilities that can meet several health and wellness goals. Initially, Joseph and Bonnie ignored it and kept progressing, growing at around 10%. They did a first-quarter review, and it was clear they were not on track to meet their financial freedom goals. They were convinced that something had to change, but they knew working harder to build new referring relationships was not scalable. They could only see so many patients daily, and hiring more therapists would add to their overhead. They needed a solution that minimized overhead growth while maximizing potential revenue. Joseph and Bonnie started taking patient requests seriously and realized a clear pattern. Patients were looking for wellness, not just treatment. Patients wanted to know if they could have a one-stop shop for preventative and therapeutic care. This was a new concept to Joseph and Bonnie, but they began exploring it and found an incredible and vast potential revenue stream in things like product offerings, DME, and more. Such a change toward integrated healthcare delivery is consistent with the ongoing tendency within the pharmaceutical sector to develop into wellness providers with patient-centric services (Moreno, 2019). This represents a larger healthcare shift from treating sickness to promoting well-being. Pharmaceutical corporations are expanding their position to include disease prevention, wellness, and patient-centric services for different health needs. Patients want a single source of preventative and therapeutic care. At first, Joseph and Bonnie only wanted to add what they could manage and keep the specialty singular. However, it soon became clear that their patients were looking for a more sophisticated preventative care so they hired a part-time nutritionist who turned into a full-time nutritionist. They bought used fitness equipment and hired a part-time fitness instructor who turned into a full-time instructor (Joseph recently replaced this person as the full-time trainer because of his personal love of fitness; the perks of being the boss). So what is value adding? Is it simply the addition of multiple complementary specialties into your practice? Maybe. Recent developments in primary and pharmacy care have demonstrated that value addition can be achieved by implementing cutting-edge health methods like digital medicines and remote patient monitoring (Smith, 2021). Value-adding extends beyond incorporating diverse specialties. Digital medicines and remote patient monitoring improve patient care and convenience. These strategies satisfy patients’ desire for individualized, accessible treatment, bringing value to a practice. It could also be the addition of community events, marble floors in the patient bathroom, or a cooling station with fancy refreshments. The true value add in a practice is unique to the patient community. It’s a matter of listening to the value-adds they seek and finding a way to accommodate them that supports the larger purpose and mission. If your practice is in a really nice part of town and you managed to get a great deal on space but are short on cash, it could be a matter of setting up one fancy area in your practice that you can afford to spruce up (it should also be functional, before you go replacing drapes). Whatever change you attempt needs to address two things: Patient requests – Surveys often help the most in this area Patient function – You want the value to add(s) to be usable in some way that improves the patient’s experience both individually and as a group   A fancy cooling station with multiple settings, fruit, vegetable-enhanced water, and more can get patients talking and feeling fancy. Often these changes can also help enhance the practice’s

Practice owners seeking better solutions often start with a vision of increased practice profitability while treating reasonable patient volumes. Their vision spans multiple aspects, including better reach to prospective patients, better reimbursement rates, full and timely payments by insurance companies, less time spent on visit documentation, improved documentation quality for better clinical follow-up and lower audit risk, and more free time for family. However, that vision conflicts directly with the payers’ goals to reduce costs and increase revenues. Payers’ goals directly conflict with a provider’s vision because cost savings for payers simply mean that providers treat more patients at lower reimbursement rates—or, in other words, providers work harder for less money. In addition to the basic payer-provider conflict, visionary practice owners must face the resistance of their office managers and colleagues. These people may be skeptical because they don’t trust the owner, have seen five other failed initiatives, or think they might lose something with the change. Significant time, enthusiasm, and resources are needed to change practice processes and technology and to retrain personnel while simultaneously managing the practice and treating patients. The challenge of overcoming resistance to change and implementing it in your practice is akin to enhancing airplane engineering while keeping the plane in the air. Thus, medical practice owners often find themselves in a dilemma between adopting new solutions or compromising the vision and returning to the old ways, along with shrinking revenues and growing frustration. One key area of medical practice that requires a huge transition is shifting from paper-based records to an electronic health record (EHR) system. Shifting from one EHR system to another is also burdensome and requires a systematic approach to achieve results. Several internet-based software and tools can aid medical practices in transitioning to electronic records successfully, leading to maximized outputs and better service delivery to patients. We shall look at how to adopt this change using a change model. EHR and billing processes can help providers cut costs, improve the quality and safety of care, and enhance the productivity of the employees. Most practices have adopted EHR and electronic billing systems to achieve the above goals, whereas some have stuck to using paper documentation and filing systems. Paper-based records are often tiresome to retrieve, prone to errors and misplacements in addition to being bulky and space-consuming to store. Paper-based billing systems have also been shown to take longer claims processing times than EHR due to the time taken to verify manually. To fully realize change and adopt it into practice, a stepwise approach has to be taken, failure to which frustrations and complacencies are bound to occur, leading to regression to previous ways. John Kotter, a Harvard Business School professor and the world’s foremost authority on leadership and change, discovered that transformation challenges span multiple industries and share the same characteristics. His book Leading Change lists an eight-step process for implementing successful transformations. The eight steps can be divided into 3 phases: creating the climate for change, energizing & enabling them, and implementing and sustaining the change (National Learning Consortium, 2013). The figure below illustrates these three phases. Figure 1: The three phases of Kotter’s eight-step change management model This model has successfully been used to help transition into an electronic health records system in clinical practices. For instance, North Shore Medical Center in Chicago, Illinois, successfully transitioned from 100 percent paper-based medical records to 100 percent electronic records in 2013 using Kotter’s eight-step model (Martin and Voynov, 2014). An orthopedic practice group in Ontario, Canada, also successfully transitioned from paper records to electronic records, achieving more than a 95% threshold using Kotter’s change model (Auguste, 2013). We shall look into the eight steps in detail using an example of a healthcare practice that desires to transition from paper-based records to electronic health records and billing. Step 1: Create a sense of urgency. In this step, a health practice can provide evidence to its employees on the need for an EHR. This can include faster claims processing, less bulky storage space, easy records retrieval, and better security. At this stage, the aim is for employees to buy into EHR and keep talking about the proposed change. Step 2: Form a powerful coalition. To help convince employees that change is necessary, the practice can develop a committee of committed and passionate individuals who constantly champion EHR. These individuals can work as a team to help identify barriers to implementation as well as help remind other employees of the need for EHR constantly. Step 3- Create a vision for change. The practice can develop a clear and concise vision through the committee, which motivates transition. An example of a vision would be establishing the most secure health records for clinic patients. Step 4: Communicate the vision for buy-in. Once the vision is created, it must be communicated to the employees clearly explaining the benefits to encourage buy-in. This can be achieved through face-to-face meetings, sending email reminders on the transition from paper to EHR, and individual interviews. Step 5: Remove obstacles. There are 5 categories of barriers hinder any change from occurring in an organization, the biggest of which are complacency and resistance to change (IvyPanda, 2020). The 5 categories include complacency, Limited sharing of the vision, Different obstacles to the vision, Inability to accomplish short-term wins, and failure to solidify the change in the practice culture. Let’s briefly talk about the five categories of barriers. 1. Complacency– This is the most deadly of practice change management problems. Suppose you just plunge ahead with a new electronic medical records (EMR) system or billing process without first establishing a shared sense of immediate need or urgency because of increased audit risk or shrinking revenue. In that case, natural complacency takes over—and the entire change effort fails. It’s hard to drive people out of their comfort zones. Past failures, the lack of a visible crisis, low-performance standards, and insufficient feedback from doctors, office personnel, and patients—all add up to turning the best-intended change initiatives

DO YOU know a practice owner who wants more patients in her clinic, better pay-per-visit, and better collections? We all know healthcare practice owners who want to remain independent and grow and yet are frustrated by insurance companies and continuous battles to get paid and stay compliant. Now, as a patient, do you like visiting a healthcare practice, receiving bills, and reconciling them with your insurance company? You are not alone. As it turns out, most other people do not like their patient experience. The problem is that patient and independent practice needs have evolved in step with society and technology, but management methodology remained in the 19th century. There’s a fundamental mismatch between how healthcare practices and patients are managed — and the practice owners’ and patients’ expectations. We came to a startling observation: patients no longer want their care to be managed the way it used to be managed in the previous century. And yet, practice owners still use their old methods to memory-manage their practice. Who is taking advantage of this mismatch? The insurance companies – payers. From the outset, we knew that healthcare costs are spiraling out of control. We also knew that insurance companies, medical equipment manufacturers, pharmaceuticals, and hospital executives have been all making handsome returns and benefitting from healthcare cost growth. One question bothered us: why are the practice owners unable to participate in that growth? How was it that the key contributors to healthcare service were excluded from fair compensation for their work and grew exceedingly frustrated with rules and regulations? Some providers were selling their practices to join larger networks or hospitals, and others were moving to different industries. National studies have shown that physician burnout rates are climbing up. For instance, Mayo Clinic Proceedings reported that the prevalence of burnout among U.S. physicians was 63% in 2021, compared with 38% in 2020, 44% in 2017, 54% in 2014, and 46% in 2011.     We also noticed that with experience, medical billing managers start cherry-picking insurance companies for easy follow-up. So, the practice owners could not get paid on time and in full by a growing number of insurance companies (payers). The more obstacles payers pose – the less paid the providers are. Payers were stacking the game against the providers by continuously adding new rules to reduce payments and increasing the frequency of provider audits. In addition to continuous consolidation, resulting in scarcity of payers (a market structure known in economics as Oligopsony), which allows the payers to drive the reimbursement fees down, they also have a two-pronged resource advantage:   attract Ivy-league MBAs to build sophisticated claim-processing protocols and discover every little pretext to deny or delay claim payment leverage the most powerful digital technology to implement those protocols on the ever-growing volume of claims.   ClinicMind was founded to address two basic challenges facing providers: a patient-provider expectations mismatch and payer-provider adversity. First, the patients have transformed how they expect healthcare service delivery, but practice owners have not adapted their practice management methodology. Second, insurance payers underpay and delay payments because they make a substantial profit from the “float.” The float is the money insurers hold onto between the time they collect premiums and the time they pay out claims.       In summary,  1. The Basic Mismatch Between Patients and Providers: a. Background:  The healthcare industry has undergone significant changes in recent years, with patients becoming more proactive in managing their healthcare and demanding a different level of service. This transformation is largely due to increased access to health information through the Internet and the rise of patient-centered care models. However, many practice owners, particularly in traditional healthcare settings, have not adapted their practice management methodology to meet these changing patient expectations.   b. Conflict: Patient Expectations: Patients today expect convenience, transparency, and a more personalized approach to healthcare. They want to schedule appointments online, access their medical records easily, and receive timely, clear communication from their healthcare providers. Provider Resistance: Many practice owners and healthcare providers are accustomed to traditional, paper-based methods and may hesitate to embrace digital technologies or change their established processes. This resistance can result from the comfort with the status quo, fear of the unknown, or high implementation costs.   c. Resolution: To resolve this conflict, healthcare practices must adapt to the changing landscape. This may involve investing in electronic health records (EHR) systems, online appointment scheduling, telemedicine services, and more. Additionally, training staff and providers to use these technologies effectively is crucial. Clear communication with patients about these changes, the benefits they bring, and how data security and privacy are maintained can help build trust and reduce resistance.   2. Payer-Provider Adversity: a. Background: In the healthcare system, insurance payers (such as health insurance companies) often maintain a substantial portion of their profit through a financial mechanism called the “float.” The float is the money insurers hold onto between the time they collect premiums and the time they pay out claims. This float can represent a significant source of income for payers. However, it can create a conflict of interest with healthcare providers.   b. Conflict: Payer Profit: Insurance payers benefit from maintaining a healthy float, as they can invest these funds and earn returns. The larger the float, the more profit they can potentially make. Payers have a significant advantage over the providers because of the oligopsony and because of significantly larger resources for better talent hiring and data processing. Provider Concerns: Healthcare providers, on the other hand, often face challenges in receiving timely and appropriate payments from payers. Delays or disputes in claims processing can impact their cash flow and ability to provide care. Providers feel that payers prioritize maintaining their float over ensuring prompt reimbursement.   c. Resolution: Transparency and fair contracting: Establish clear and fair contracts between payers and providers that outline payment terms, including prompt payment schedules and dispute resolution mechanisms. Industry consolidation: Metcalf’s Law states that the value of a network is

Introduction Factoring can improve cash flow and operational efficiencies, and it is used in many industries, including the healthcare sector. With this strategy, businesses sell their accounts receivable at a discount to a factoring company (the factor), giving them access to quick cash. The burden of recovering the debt from the consumer who has not paid their invoice is transferred to the factoring company. The corporation has access to its earnings immediately, skipping the customary payout period (Ferguson, 2020, Factris, 2021).   Popularity of Factoring The worldwide factoring services industry will reach USD 3.5 billion by 2032, growing 8.5% annually. The market’s growth is driven by cash flow management, working capital financing, and SMEs’ use of factoring services (FID Reports and Data, 2023). The U.S. factoring services market will reach USD 287.61 billion by 2030, growing 8.1% from  153.96 billion in 2022 (Grand View Research, 2023).   According to a survey, factoring services have grown in popularity, especially among Micro, Small, and Medium-Sized Enterprises (MSMEs) that have trouble securing appropriate financing, particularly in working capital.  There are 127 factoring companies in the US and Canada.  Mazon Associates in Dallas, Crown Financial in Houston, Provident Commercial Finance in Chattanooga, Bankers Factoring near Atlanta, J D Factors in Los Angeles, and Velocity Financial in Midland are considered to be the top-performing 2023 companies (Factoring Club, 2023).  A few other examples include (Treece, 2023): FundThrough offers 100% advance rates on up to $10 million in finance, with costs starting at 2.75%.   Riviera Finance offers 95% advances on $5,000–$2 million loans. They are known for their individualized service and face-to-face knowledge. altLINE offers up to 90% advances and can quote lending amounts. They specialize in huge invoices and charge 0.50% APR. TCI Business Capital finance $50,000–$10 million at 60%–90% advance rates. They offer bespoke factoring solutions and don’t disclose their APR.   Healthcare providers frequently encounter delays in receiving reimbursements from insurance companies. The quality of healthcare providers’ services may suffer due to delays (Fundbox, 2023). Healthcare providers use factoring firms to speed up the payment procedure. They sell the health insurance claims—basically unpaid invoices—to factoring companies, who recover the claim payments from the insurance providers. By ensuring prompt claim payouts, this method aids healthcare providers in maintaining their highest levels of operational effectiveness.  On the other hand, some practice owners may disapprove of the factor’s specific approach to managing patient or payer interactions (Factris, 2021).     Factoring Process  Initially, healthcare vendors or medical providers send invoices (claims) to either a medical provider or third-party payer (Medicaid, Medicare, private insurance companies) for services rendered or goods provided. Following this, a copy of the invoices, along with any supporting documentation, is submitted to a factoring company like PRN Funding, LLC (PRN Funding, 2020). Subsequently, the factoring company purchases these invoices and advances 80-90% of their face value, with funds typically deposited directly into the vendor’s or provider’s bank account within 24-72 hours. The remaining percentage is used as a buffer in case some bills do not get paid or if there are billing errors. Eventually, the reserve, less the factoring fee, is released back to the vendor or provider after receiving payments (PRN Funding, 2020). Step-by-Step: Healthcare vendors or medical providers send medical claims to medical providers or third-party payers (such as Medicaid, Medicare, or private insurance companies). A factoring business (the factor)  Receives copies of the invoices and any necessary supporting documentation. Purchases these invoices at a discount, typically around 80-90% of their face value. Advances the funds directly into the vendor’s or provider’s bank account within 24-72 hours. Holds a portion of the invoice amount as a reserve in case some bills go unpaid or there are billing errors. Assumes the responsibility of collecting outstanding payments from insurance providers, relieving the healthcare provider from the burden of debt collection. Collects the payments received from insurance companies or third-party payers. Releases the reserve, minus the factoring fee, back to the vendor or provider once the payments are received.   How does the factor estimate the quality of the outstanding claims? The factor assesses the quality of outstanding claims through various methods and criteria.   This assessment helps determine the likelihood of prompt payment, helps minimize non-payment risk, and ensures that the factor can provide immediate capital to healthcare providers while maintaining a reasonable level of risk.  Here’s how the factor determines the quality of the outstanding claims: Evaluation of the payer: The factor examines the insurance companies or third-party payers responsible for reimbursing the claims. They consider  the payer’s reputation, track record of timely payments, financial stability, credit scores, and payment history.  Specific policies, guidelines, and requirements for claim processing. These include claim submission deadlines, pre-authorization requirements, and claim acceptance rates. Collaboration with healthcare providers: Factors collaborate closely with healthcare providers to gather information about outstanding claims. Providers may share their experiences with different payers, providing valuable insights into the quality and reliability of the claims. Verification of claim documentation: The factor reviews the supporting documentation accompanying the outstanding claims. This includes verifying the accuracy and completeness of the medical records, coding, and billing information. Thorough documentation ensures that the claims are valid and are more likely to be paid. Analysis of historical data: The factor analyzes the provider’s historical payment patterns from different insurance companies or payers. This analysis helps identify any trends or patterns of delayed payments or denials, providing insights into the quality and reliability of the outstanding claims. Industry Knowledge and Expertise: Factors with experience in the healthcare industry develop expertise and knowledge about various payers, their reimbursement practices, and the industry’s dynamics. They stay updated with industry news, regulatory changes, and trends that may affect payment processes. This industry knowledge enables them to predict payment delays and amounts.   Strategies for Choosing the Best Factor for Your Practice The factor selection decision depends on the factor’s stability and track record, the factoring service fees (2%-3.5% monthly was typical in 2022), the terms of the factoring agreement, the type

This blog chapter discusses the importance of standard operating procedures (SOPs) and checklists in problem resolution within the context of complex billing processes, with a focus on medical billing. It explores the characteristics of an effective tracking system for problem management and emphasizes the benefits of using tasks over email or other communication tools. The article provides a structured approach to creating tasks and highlights the significance of transparency, accountability, and measurement in this process.

The use of Software as a Service (SaaS) in healthcare has transformed medical practice management by offering scalable, cost-effective, and AI-integrated solutions. SaaS shifts system management responsibilities to vendors, allowing healthcare providers to access applications without the need for significant upfront investments. Selection criteria for a SaaS vendor include functionality, training, performance, HIPAA compliance, and more. Platforms like Capterra and G2 simplify the evaluation process, with Genesis Chiropractic Software being recognized as a leader in chiropractic software. In conclusion, SaaS in healthcare offers convenience and efficiency, with AI integration enhancing automation, patient engagement, and data security.

Patient loyalty is essential for the success of healthcare organizations, both in terms of recurring revenue and new patient acquisition. Factors like patient satisfaction, service quality, trust, and effective communication influence patient loyalty. Timely communication, a patient communication portal, and the use of advanced technology, including AI, can enhance the patient experience and foster loyalty. Patient portals offer features like appointment scheduling, secure access to health records, secure messaging, and billing management. AI can personalize patient communication and provide real-time insights, improving patient engagement and adherence.

The U.S. faces escalating healthcare spending, with 2021 per capita costs reaching $12,318. Compared to advanced economies, the U.S. spent double the amount on healthcare. Factors contributing to this include an aging population, expensive medical innovations, and defensive medicine practices. Chronic diseases among older adults are a significant cost driver. Rising healthcare expenditures and declining physician income create a paradox in the industry. The excessive cost of medical innovation, demographic shifts, and defensive medical practices challenge healthcare affordability and sustainability.

Mergers and acquisitions benefit healthcare by expanding services and improving patient care. However, they entail complexities, expenses, and risks. Research reveals reduced operating expenses and improved patient outcomes, but also increased prices with no clear quality improvements. To mitigate risks and achieve success, a strong platform business is crucial, technologically equipped for efficient network growth and integration.

ClinicMind introduces Live Chat for real-time client support, enhancing convenience and issue resolution. New features like Incoming Fax Queue, Roster Check-in, and image chart components improve document management and interactions. The patient portal has been rebranded as MyClinicMind. Social media’s role in healthcare engagement is emphasized. The Production Roadmap outlines upcoming features. Effective denial and appeal management are vital for private practices to optimize revenue. ClinicMind’s platform simplifies practice management and billing accuracy.

Effective denial and appeal management is essential for private practices, with studies showing that up to 90% of insurance denials are preventable. Common reasons for denials include medical necessity issues, duplicate billing, and more. Best practices include monitoring claims submission reports and training staff for efficient denial management. Streamlining the approval process and compliance checks are key to preventing denials. ClinicMind’s EHR/RCM platform helps automate workflows and improve practice management, ensuring accurate billing and documentation.

Health insurance audits can be daunting for private practices. Auditors aim to ensure correct billing and proper claims handling. Audits can be routine or event-triggered, conducted by payors, either commercial insurance providers or government entities. Preparation and education are key to surviving audits. Providers should maintain compliant documentation, understand the audit process, and use practice management platforms like ClinicMind to streamline recordkeeping and compliance, making audits less intimidating.

Analytics play a crucial role in optimizing insurance management for private practices and healthcare providers. Monitoring approvals, denials, and appeals provides valuable insights. Identifying the specific reasons behind denials, like coding errors or insufficient documentation, helps address underlying issues. Analytics offer quantifiable insights to streamline operations, reduce inconsistencies, and adapt to evolving circumstances. ClinicMind’s EHR/RCM platform offers comprehensive reporting and analytics features to enhance insurance management, improving practice efficiency.

The health insurance landscape is continually evolving, posing challenges for healthcare providers. To stay updated, practitioners should read industry news and share vital updates within their practice. It’s important to schedule regular compliance checks, both human and technology-related, to ensure adherence to standards. Staying informed about important dates and changes is essential. Implementing efficient practice management tools, like ClinicMind’s EHR and RCM software, can streamline operations and keep practices compliant in the ever-changing health insurance industry.

Creating a profitable and fair fee schedule is crucial for private practices. It should cover true service costs, not just insurance reimbursement. Align your rates with insurance provider maximums and industry standards. Ensure consistency and notify patients in advance of any fee changes. Consider your practice’s operating expenses for an accurate fee structure. ClinicMind’s EHR/RCM platform simplifies fee schedule management and practice operations.

Medical coding and billing are essential for efficient revenue cycle management (RCM). Attention to reimbursements and accounts receivables (AR) is vital, as insurance companies often underpay. Strive to maintain a clean claims rate above 95% to avoid resubmissions and appeals. Double-check claims for accuracy to prevent insurance denials due to errors. ClinicMind’s RCM software streamlines billing and coding, reducing challenges.

ClinicMind has acquired Affinity Billing to expand its revenue cycle management (RCM) services. Monthly updates include scheduler customization, waiting list management, and mobile EHR enhancements. ClinicMind updates faxing service pricing for better quality. The patient portal, CareToMe, is rebranded as MyClinicMind. Affinity Billing clients will now receive invoices from ClinicMind.

Maximizing private practice revenues hinges on effective billing practices, automation, and clear collections procedures. Verify patient eligibility, streamline payment processes, and focus on key performance indicators (KPIs). ClinicMind, a practice management platform, provides integrated support to optimize the revenue cycle and offers solutions for billing and documentation, ultimately improving patient care while maintaining profitability.

Private practice reputation management is crucial in today’s digital age. A proactive approach is recommended, as being reactive may lead to reputation damage. Encourage patient reviews, referrals, and word-of-mouth marketing to boost your reputation. Address negative reviews promptly to show you care. Reputation management companies and in-house efforts can help. ClinicMind’s practice management software aids in streamlining processes, allowing you to focus on patient care.

Efficiency is key in structuring a successful private practice. Enabling patients to manage their care through tools and technology streamlines operations. Automation can handle scheduling, payments, and insurance, saving time. Being agile and scalable is vital, especially with cloud-based solutions offering secure and accessible records. ClinicMind’s practice management tools, including EHR, billing, and scheduling, can enhance practice efficiency and productivity, allowing physicians to focus on patient care.

Establishing a successful private practice requires careful planning. Physicians should be prepared to balance both business and patient care aspects. Assess your capabilities, challenges, opportunities, and concerns (Four C’s) when creating your business plan. Regularly review and update your plan to adapt to changes and growth. ClinicMind offers practice management solutions to streamline business operations, allowing physicians to focus on patient care.

Building a strong referral network is vital for private practice success. Referral marketing and patient reviews play a significant role. Implement a well-structured referral program, use technology tools, and pay attention to patient feedback and reviews. Embrace social media and digital marketing for outreach. Overcome challenges in incentivizing referrals with genuine engagement. ClinicMind’s comprehensive practice management solution supports streamlined operations and fosters a positive reputation, encouraging referrals.

The rise of mobile apps in healthcare is transforming private practice management and patient engagement. These apps enhance patient records management, scheduling, billing, and more, offering accessibility to healthcare providers and patients. Differentiating between practice management and patient apps is crucial, and they can work together to streamline practice operations. ClinicMind software offers a comprehensive solution, including EHR/RCM, credentialing, and insurance management, accessible through mobile devices, enhancing practice efficiency and patient care.

Effective patient engagement in private practice is vital for improving healthcare outcomes. The challenges include patient passivity and the disconnect created by telehealth. Providers should leverage technology to facilitate patient engagement. Well-designed EHRs, patient management apps, and scheduling tools help build rapport and enhance patient involvement. Gathering feedback from patients is a valuable step to understand and improve engagement. ClinicMind offers a comprehensive practice management platform to streamline operations, giving providers more time for patient engagement.

Credentialing for insurance coverage is a vital step when establishing a private practice. The process involves application, information verification, and contract negotiation with insurance providers. It typically takes 90-120 days to complete. Essential information includes NPI and CAQH ID, malpractice insurance, and tax-related details. A comprehensive practice management platform like ClinicMind streamlines credentialing, along with billing, scheduling, and other business aspects, allowing providers to focus on patient care.

In private practice, focusing on patient care amidst administrative tasks is a challenge. To provide a more patient-focused service, doctors can utilize technology and automation. Outsourcing is an option for administrative tasks, such as scheduling and billing. Delegating work and integrating a practice management platform, like ClinicMind, allows for seamless operations. With EHR, billing, and scheduling in the cloud, healthcare professionals can concentrate on patient care. ClinicMind also offers billing, credentialing, and consultation services, making it a valuable practice management tool.

A solid content strategy is crucial for private practice chiropractors. Planning an effective strategy involves deciding on the types of content to create, including blogs, social media posts, email campaigns, eBooks, infographics, videos, and more. Positioning yourself as an industry expert is vital, and staying ahead of competitors by offering superior content is key. You can manage your content strategy in-house or consider outsourcing to professionals who can enhance your practice’s online presence and reputation. ClinicMind’s practice management solution can help streamline your operations, allowing you to focus on content marketing and patient care.

Blogging is an essential part of content marketing for private practice owners like chiropractors. Planning an effective strategy is crucial, and considering whether to hire a professional to manage your blog is a viable option. To make the most of your blog, focus on relevant topics such as conditions, treatments, industry news, practice updates, and patient education. Blogging can help build your practice’s reputation and authority in the competitive medical field. ClinicMind’s practice management solution can streamline operations, allowing you more time for effective blogging and content marketing.

Production servers now offer several new features. The Patient Messages Mailbox enhances patient communication and experiences. Automatic Document Publishing allows documents to be shared on the patient portal based on appointments. Patient phone numbers can be encoded as barcodes. Patient statements now offer the option to display the date of birth. XDocs Macro Management simplifies macro renaming and management. Flexnote has improved visibility for salted values and a new option for addendums.

Creating a website for your private practice is crucial. To make it an effective marketing tool, ensure you have essential pages like the homepage, about, and contact pages. Target local keywords with dedicated service pages for various treatments and locations served. Develop a strong call-to-action landing page to enhance conversion rates. Link to social media pages and offer an email newsletter to capture leads. Invest in content marketing by adding a blog section and keep your site updated regularly for maximum impact.

Social media offers a valuable platform for healthcare practitioners to cultivate relationships, showcase values, and validate expertise. It can serve as an excellent recruitment tool to attract top talent. Employ organic strategies like using hashtags, posting original photos, and planning content in advance. Paid social media strategies can grow your following and drive website traffic, but they require research and adherence to best practices. Developing a strong social media presence takes time, effort, and consistency.

Understanding the tax implications of running a private practice is crucial for managing your finances effectively. Self-employment tax, payroll tax, and corporate tax are key considerations. It’s important to budget for self-employment tax, make quarterly estimated payments, and outsource payroll tax management for convenience. Additionally, explore deductions like the QBI deduction, professional organization fees, educational expenses, software costs, and office expenses to optimize your tax strategy. Consulting a tax advisor for guidance is advisable.

More than ever before, consumers are paying close attention to how businesses operate. This means every interaction counts, with both staff and patients, to showcase your practice’s culture and values. However, offering satisfactory service isn’t necessarily enough on its own to maintain a good image. At a time when anyone can make their opinion heard online, private practice owners need to be more involved in public relations than ever. This means managing interactions in person and online, and also keeping your eyes on social media, Google reviews, and the local news. Here’s what you need to manage your PR effectively.  What are Public Relations? Public relations (PR) is the practice of managing how information is shared by your practice. While most of the information you share in PR engagements will be positive — like announcing a new team member or service — some will be negative, as would be the case with a security incident. In all cases, great PR will allow you to get the most benefit out of good events and minimize the impact of bad events.  It’s worth noting that PR is different from publicity, although one often involves the other. Publicity generally refers to information that is published by external parties, which means you’ll have little to no control over it. Like PR, publicity can be both positive and negative. Properly responding to and handling publicity is a matter of good PR strategies.  Strategies for Positive Public Relations As a private practice, you have the ability to impact your local community in countless positive ways. However, it’s easy for the public to ignore things like equipment upgrades when they don’t really see a direct benefit for themselves. Yet, failing to call attention to milestones, upgrades, and improvements in your practice can make it harder to cultivate a strong brand. For this reason, you should have multiple strategies in place for showcasing all positive PR things, big and small. Writing Your Own Press Releases One of the easiest ways to call attention to positive things you wish to announce is to make a press release for your website. This may be just 300-500 words long, but it’s a great way to let your website visitors know about it. You can then syndicate it yourself by posting it on social media and sending it to your email list.  Getting Your Press Release Published If it’s a grand enough announcement or a slow news week, another positive PR strategy you can use is sending your press release to local publications. In fact, taking the time to contact your local newspapers and news stations is a great way to get the email address of whoever is in charge of managing press releases. Once you have that info, you can send your press releases to them directly and cross your fingers that they’ll put it in print. Being Featured on the News For particularly exciting announcements that impact the community at large (like the opening of a new location), you should go the extra mile and pitch the story to local reporters, too. While you might not score an interview or on-site segment, a mere mention of it will help call attention to your practice. From there, you can follow up by tagging the news network on social media thanking them to inform and remind your followers of the feature.  Combating Negative Public Relations When a negative PR event occurs, your goal should be crisis aversion. You’ll rarely be able to escape a negative event without any impact but acting swiftly and empathetically can help you ensure the event is forgotten and forgiven as quickly as possible.  Acknowledge the Event One of the worst things you can do when negative PR happens is trying to brush it under the rug. While you pretend like it isn’t happening, your audience will be waiting for a response, and silence can leave them thinking the worst about you. While you might think you’re calling more attention to the event, properly responding to the negative PR will help you minimize its impact. A great example of this is if a consumer posts a negative review about your practice online, perhaps chastising your team for canceling their appointment last minute. In this case, you could send a public response to their review and reach out to them directly with an apology. Depending on the event, you might even post a public apology to your social media page and website, preferably in video form. While you might not think that a certain event justifies such a big response, taking even small instances of negative PR so seriously will help showcase your practice’s integrity, which will go a long way in protecting and building your image.  Be As Honest as Possible  Misspeaking or lying in the wake of negative PR will only compound the problem. Regardless of what the negative PR is about, it’s essential that your practice handles it as honestly as you can within the constraints of confidentiality clauses or ongoing investigations.  Telling your side of the story is an important part of addressing the situation. However, in addition to making sure you’re only telling the facts, you need to make sure you’re not accidentally disclosing information you shouldn’t.  With that said, it can certainly be frustrating if you know that negative PR simply isn’t true, but you’re not allowed to share the proof that backs up that claim. For instance, maybe the review left by a disgruntled person saying you canceled their appointment was completely false. In this instance, you might feel like it’s your word against theirs, and the last thing you want to do is come across as dismissive or dishonest. Consulting with a lawyer will help you avoid potential problems when handling negative PR so you know what you can share and how.  Create a Positive Spin When your practice makes a mistake, you have to own up to it. However, once you have sufficiently acknowledged the issue, apologized for it

Choosing the right legal and tax structure for your private practice is crucial. You can opt for an LLC, a regular corporation (Inc), an S-Corp, or a C-Corp, with each having distinct tax implications. S-Corps are pass-through entities with specific shareholder and ownership limitations, while C-Corps are separate taxable entities that allow unlimited shareholders. Consult with a tax advisor to determine the best fit for your practice’s goals.

Leveraging Google for your private practice goes beyond paid ads. Focus on Google My Business for free profile management and customer engagement. Utilize Google Analytics for in-depth website insights and SEO tracking. Google Ads, a PPC advertising platform, helps you reach a targeted audience in search results and on various platforms. These three areas can significantly boost your practice’s online presence and patient outreach.

New features and optimizations have been rolled out on production servers. These include a Patient Responsibility Estimator for viewing patient costs, an update to the Billing Widget allowing users to set favorites for modifiers, Auto Check-out by Appointment Type, improved Schedule Alerts for patient balances, and enhancements in documentation tools like FlexNote and XDocs. Patient Portal optimizations and a new Appointment Type Summary Report are also part of this update.

A website is a valuable asset for your private practice. It helps attract the right clients, build credibility, enhance the patient experience, and strengthen relationships. Creating content and providing resources can set you apart. Building a website can be straightforward using platforms like WordPress or drag-and-drop builders, and choosing the right hosting is crucial. Invest in high-quality content to reflect your practice’s voice and values.

The insurance industry relies on shared risk and managing the financial float is crucial for profitability. Insurance companies invest premiums to maximize returns while maintaining the float’s value. Service providers, like hospitals and private practices, face challenges in filing claims correctly to avoid errors and delays in payments. Implementing advanced software, like ClinicMind, helps streamline practice management, reduce administrative burdens, and ensure accurate claims processing, leveling the playing field between payers and providers.

Switching to a new Electronic Health Record (EHR) system is a significant decision for healthcare practices. Before making the switch, consider questions such as change management readiness, time for workflow redesign, patient preparedness, and the software’s ability to handle complex intake forms. Selecting an EHR provider with strong support and custom workflows, like ClinicMind, can make the transition smoother and more efficient. ClinicMind’s expertise and features help practices navigate the migration process effectively.

Payor-provider adversity in the healthcare industry results from opposing interests between insurance payors (companies) and healthcare providers (clinics). Payors aim to minimize claims payouts and delay payments, while providers rely on timely claims processing. Technological solutions like ClinicMind help level the playing field, reducing errors in claims processing. ClinicMind streamlines administrative tasks, leading to better efficiency and revenue management for healthcare practices.

An Electronic Health Record (EHR) is a digital system designed to store and manage patients’ health information. EHRs facilitate physician documentation, provide secure storage of patient data, and offer features for automated scheduling, billing, reporting, and more. Selecting the right EHR is crucial for efficient healthcare operations. Factors to consider when choosing an EHR include technical requirements, ease of data migration, software support, security, scalability, and staff adoption. ClinicMind is a cloud-based EHR and practice management system that offers customization, training, and support for healthcare providers during the transition to a new EHR.

The text discusses the challenges and benefits of transitioning to a new Electronic Health Record (EHR) system. It highlights that many existing EHRs may no longer meet the evolving needs of healthcare practices. The transition process, while initially daunting, can lead to more efficient patient management, improved practice management, and enhanced recordkeeping. ClinicMind is presented as a solution that offers comprehensive training, support, and full-service capabilities to ease the transition to a new EHR and practice management system.

Payor adversity in healthcare refers to payment disputes, delays, and billing challenges with various payors, impacting providers’ revenue and workflow. Electronic Health Records (EHR) and practice management software, like ClinicMind, offer solutions to streamline payment processes, manage billing efficiently, and track payments. ClinicMind provides customizable EHR and practice management tools with comprehensive training and support for healthcare providers.

Financial float in insurance refers to funds retained by insurance companies through the difference between collected premiums and paid claims. Insurers invest this surplus to generate profits. Payer-provider adversity arises when insurance companies delay or deny payments, impacting medical providers. ClinicMind’s EHR and billing technology help providers streamline billing processes, identify and fix claim errors, and efficiently manage payments, reducing delays and disputes.

The CURES Act, enacted in 2016, focuses on streamlining healthcare information sharing, improving mental health services, addressing the opioid crisis, and enhancing privacy protections. It promotes electronic health information (EHI) accessibility while prohibiting information blocking practices. Information blocking encompasses any interference with EHI flow, primarily in electronic health records. ClinicMind, an ONC-certified solution, ensures EHI privacy and accessibility, streamlining practice management and compliance with CURES Act guidelines.

The 988 Crisis Lifeline, launched on July 1, 2022, is a suicide prevention network connecting over 200 crisis call centers across the U.S. It provides immediate access to mental health professionals for individuals in crisis, offering an alternative to involving police and first responders in mental health situations. While promising, concerns include the potential dispatch of police officers in emergencies, urging the need for continued improvements to the crisis response system.

Marketing is crucial for private practices to attract new clients and grow. It involves promoting the practice and its services to the public and potential patients, driving sales and increasing ROI. Marketing builds brand awareness, personalized connections, and helps to establish a preliminary reputation. It also creates awareness about services and treatments offered, enabling the practice to stand out. Marketing analytics and community engagement are valuable tools for evaluation and engagement. A strategic, adaptable marketing plan is essential for success.

Credentialing, or getting on an insurance panel, is crucial for healthcare providers. It boosts reputation, expands the client base, and facilitates referrals. Steps include researching insurance companies, gathering necessary data, registering with CAQH, and submitting applications. Streamlining the process is possible with expert solutions like ClinicMind, making the process more efficient for quicker access to insurance reimbursement.

Starting a private medical practice is a significant decision. It offers more control but requires balancing business and patient care. Your salary structure changes, and you must attract patients by identifying unmet needs and potentially accepting insurance. Credentialing is crucial. A practice manager can help with business operations, and ClinicMind software provides comprehensive practice management solutions, streamlining various tasks and improving patient care.

Medical professionals must handle billing efficiently. While in-house billing may seem ideal, it comes with numerous challenges. Training, salary, compliance, and accountability issues can affect productivity and costs. Third-party billing services are a cost-effective alternative, with trained staff, expertise in compliance, and greater efficiency. ClinicMind offers full-service billing solutions, ensuring transparency and coaching to optimize revenue for your practice.

Setting therapy rates in private practice involves balancing overhead, personal income, and future goals. Avoid mirroring competitors’ rates and relying solely on insurance reimbursement. Gradually increasing fees for new clients while grandfathering existing clients’ lower rates may lead to inconsistency. Ethical rate increases require transparent communication and notification. Adapting rates to market changes is vital for financial growth.

This series delves into using social media for chiropractic practices. Begin by identifying your target audience and selecting the right platform. TikTok, Instagram, Facebook, and LinkedIn offer distinct advantages for various demographics. Emphasize engaging video content, featuring chiropractic adjustments and educational materials. Active engagement is crucial—reply to comments and interact with others. Clearly communicate scheduling instructions, and ClinicMind can help you join insurance panels to attract more clients.

Mental health practitioners often grapple with common billing issues. Insurers might deny claims due to perceived duplicates. DSM-5 and ICD-10 code disparities can complicate billing. Partial payments for patient care activities occur, adding administrative work. Providers might discover patients are out-of-network only after claim submission. ClinicMind offers solutions: billing for diagnostic assessments and office visits on separate days, expertise in DSM-5 and ICD-10 code conversions, and the benefit of outsourcing billing to address these challenges.