To Verify or Not?

In the world of emergency ambulance transportation, we oftentimes find it hard to verify if a patient has insurance coverage at the time of treatment. Our clinician’s top priority is patient care, often leaving  responsibility for verifying insurance on the billing office.

Based on my experience, there are three things to carefully consider when creating an efficient verification process for your organization:

  1. Based upon demographic information, you can sort accounts into ‘buckets’ fairly quickly based upon several factors, such as: the age of the patient, zip code, accident or injury claims, and even employer information. This will help your verification teams to target certain payers such as Medicare, Medicaid and particular commercial payers based upon this demographic information.
  2. There are several vendors or internal procedures that you can deploy to automate the verification process without manual verification. This strategy will assist in decreasing your days to bill along with you FTE count by allowing your billing office to focus your human resources on back end processes, such as appeals and challenging improper payments. As an example, let’s say you have Medicare information, but have not verified it for accuracy. Instead of manually calling the insurance company or checking it via the website, why not just submit the claim? If the information is not accurate, the claim will reject on 1st edit. This notification is usually provided same day of submittal (or the very next day). If the information is correct, it will process through the system, and you avoided the manual verification process, thus saving your resources for those accounts that require manual intervention.
  3. Not all employees are created equal. Some employees are better at researching and investigating than others will be. These are the individuals you want in your verification process for the accounts that need manual intervention. Focus your resources accordingly and you will be pleasantly surprised how you can increase your revenue per patient and decrease your cost per patient.

For non-emergency ambulance transportation, I strongly encourage you to set up a verification process prior to transport to determine coverage. This is not only a benefit for your service, but for the patient you serve. A patient should never be surprised during the billing process if it is within your control to notify them prior to transportation.

Remember, Prioritize. Automate. Focus. What we are intentional about we will accomplish.

Are You Using an Original or a Copy Cat?


There is definitely a difference. While an original thought or idea executed can be replicated, it is oftentimes not able to be exactly duplicated. Why is that? The duplicated idea typically has “bugs” or flaws not seen to the designers that are replicating an original. However, the original owner always knows where the flaws are and the flaws matter. This is exactly why it is important that managers of revenue cycle understand the difference when working with vendors who can assist them with perfecting their revenue cycle management.

Research is key when using vendor solutions to augment processes within your RCM systems. My team has worked with me long enough to know to never pitch an idea to me without thorough research. This research includes investigating the marketplace for similar ideas and conducting a thorough cost benefit analysis. The reason why I want them to investigate the market place for similar ideas is to get an understanding around who is an original or who is a copy cat. It is easy to copy but hard to be an original. An original is more invested in the product marketed than the copy cat. If I am looking for a solutions oriented company, I always defer to someone who is an original in their field because copy cats, by their very nature, define themselves as unoriginal. A copy cat will do if I am looking for standard product delivery.

While I understand there may be some that agree or disagree with the premise of this blog, I encourage you to think about it and how this impacts your everyday management of revenue cycle before dismissing this as not applicable. How many times have you switched vendors because they were not able to provide you with Best in Class service? Or, better yet, you dismissed them because there was another company that provided the same exact service?

Is it possible that you were looking for an “original”?

The Evolution of Self-Pay Management

Capturing More Revenue

Management of self-pay receivables has evolved drastically over the past 20 years. I remember the days when the companies I worked for would allow minimal payments from $1 to whatever someone could afford. I’m sure there are still healthcare entities allowing these practices. However, many of us have graduated to some very sophisticated processes to tackle the ever increasing issue of self-pay.

If you are achieving industry best practices you have basically admitted to average business practices. You should always be looking for ways to achieve better results than industry best practices.”

Some are implementing traditional, industry best practices. Others are going beyond and inventing new best practices. I prefer to be the latter. If you are achieving industry best practices you have basically admitted to average business practices. You should always be looking for ways to achieve better results than industry best practices.

I find some of our most creative ideas in tackling self-pay have come from staff engagement. We implemented an insurance finders fee with our collection agencies this way. An insurance finders-fee is a fee that is negotiated at a percentage of collections that is less than self-pay collections (being that our collection agency provides us with the insurance information, but we have to still file the claim and perform all the insurance follow-up).  As a result, we were able to decrease our collection costs by approximately 25%.

If you are not evolving as an RCM department then you are doing your company a disservice. In order to combat the increasing self-pay revenue cycle, it’s time to evolve, invent, and partner with solutions that improve your process.

How has your company evolved with regards to self pay management?

Payer Accountability: What does that mean?


During my almost twenty years in the healthcare industry, mostly on the provider side, there has always been this very interesting dichotomy regarding the relationship of providers and payers; That is until recently. Over the past few years I have started to see providers and payers begin to partner in trying to meet the Triple Aim objective: Improving Patient Health, Improving Patient Experience, and Reducing Healthcare Cost.


Where is Payer Accountability being discussed? Regulation is only as good as its enforcement.”


It seems that everywhere news article I read, peer-reviewed or not, everything seems to be focused on patient outcomes and what healthcare providers can do better. It’s understandable and I agree with the focus, however, where is payer accountability being discussed?  It goes without saying that there is a surmountable amount of regulations that govern that industry and it varies state by state, however, regulation is only as good as its enforcement.

At the company I work for, the cost per claim percentage that I associate with the administrative burden of holding payers accountable is substantial. This only drives up the delivery of healthcare. The healthcare industry is comprised of a majority of small businesses. While this is a great economic driver, it is detrimental for payer accountability. The main reason is that small businesses lack the resources, and sometimes the sophistication, to work the process of holding payers accountable for the regulations they are responsible for following.


Partnerships are all about accountability. If accountability is only one-sided it is not a partnership.”


Over the next several blogs, I am going to explore several areas where providers can proactively work with payers to ensure there is accountability. Partnerships are all about accountability. If accountability is only one-sided it is not a partnership. For example, if a provider has a responsibility to submit a clean claim within 90-days and does not, the payer will deny for timely filing. This is pretty elementary, and payers have claim edits in place to ensure provider compliance. As a provider, do you have an edit in place to ensure that the payer processes your clean claim within the period of time established by federal or state law, and if not the amount of interest you are owed? This is just one example of the areas we are going to explore. Remember, accountability goes both ways, and will assist not only with improving claim throughput,  but also reducing the cost of healthcare.

I am sure there are varying opinions regarding what payer accountability means to provider organizations. I would be interested in hearing from you. What are your thoughts?

How Do You View Mistakes?


Over the past twenty years of my career, I have seen numerous reactions from management when employees make mistakes. Ranging from aggressive to passive behaviors, each reaction to a mistake made produced a result.

An unknown author penned the following:

Making a mistake does not mean I’m a failure;  It just means I’ve identified an opportunity for improvement.  Making a mistake does not mean I can’t do anything right;  It does mean I have more to learn.  Making a mistake does not mean I have been a fool;  It does mean I have the courage to try something new.  Making a mistake does not mean I don’t have what it takes to get the job done;  It does mean I need to try a different approach.  Making a mistake does not mean I am inferior;  It does mean I am not perfect (just like everyone else).  Making a mistake does not mean that I should give up;  It does mean that I need to sharpen my skills and try harder.”


As a leader, if your team lacks creativity you may want to look inward. How we respond when our team members make a mistake correlates directly with creativity and initiative from our teams. If you do not allow your team to make mistakes you are doing them, and your company, a great disservice.

How we respond when our team members make a mistake correlates directly with creativity and initiative from our teams.”   – Asbel Montes

At my company, I encourage our leadership team to take initiative,  forge unchartered waters, and to think outside the box. As a team, we can always correct a mistake. In the billing department, there is nothing we do that will cause loss of life. Of course, one should not interpret what I am saying as giving your teams a license to make the same mistake over and again. That cycle is a performance problem, and would need to be addressed.  However, your team should feel that they have the ability to make decisions and try new things without fear of reprisal.

Try it. The results that you will see from your team members will make you wonder why you did not do this earlier.

Question: Have you ever worked in a culture where perfection was required with little room for mistakes? If so, how did you respond?

Are Deductibles Eating Away At Your Bottom Line?


Over the past several months, I have had many discussions with other health care revenue cycle managers regarding the increasing volume of self-pay. The major contributor appears to be related to the number of patients who have high-deductible health plans. As a result, many of us have taken a hard look at our self-pay management processes. Many practices have implemented processes to screen all insurance coverages prior to treatment, and then arrange for the patient to pay a portion or all of their deductible at the time of service. However, this approach does not help when you are a provider of emergency medical services.

Often, services that are provided to patients who have presented with an emergency condition, (i.e. ambulance transports, E.R./E.D.’s, diagnostic laboratories, pathology and many others) are filed to the patient’s insurance, without knowledge if the deductible has already been met. This is typically due to the fact that EMTALA and other federal or state regulations require health care providers to treat emergency medical conditions regardless of the ability to pay.  So, how can you manage this book of business?


The old ways of managing revenue cycle are ways of the past. It is imperative that you recreate and enhance your processes in order to produce better results. One solution to assist in evolving is the solution sponsoring my blog, Solutions Group. Click here for more information.


Your revenue cycle team should be extremely knowledgeable of what is happening in the healthcare industry today, and the different plans that patients may have. This is imperative to help with deductible and self-pay management; As the saying goes “knowledge is power.”


Get rid of processes that are no longer working. If your RCM processes have become complicated and burdensome, it’s OK to start over. Use a whiteboard to map out the life of a claim. Involve your team members and front line staff in this process. You will be surprised at the results you’ll create, when you are open to change.

Hang-on for the ride as we weather this health care hurricane over the next several years. Only those entities with an executable plan will thrive.

Does your RCM department have a plan to assist in navigating this new self-pay environment? If so, please share some of the concepts that are working well for your organization.

Are Excuses Hurting Your Bottom Line?

No Excuses

I once read a quote from Mason Cooley that said, “Excuses change nothing, but make everyone feel better.” Throughout my career in revenue cycle, I have worked for and alongside individuals who constantly made excuses why their revenue cycle could not be improved. Their excuses ranged from “It is hard to find individuals who understand revenue cycle” or “payers are constantly denying our claims inappropriately” or “reimbursement rates are too low” or better yet, “our Revenue Cycle Management (RCM) is one of the best in the industry”.  All of these were excuses to justify why innovation had stalled in their RCM divisions.

If this sounds familiar, this is a cancer that should be obliterated from your thinking, and your company’s mindset. In the book Good to Great, I read something that really stuck with me:

“The enemy of great is good…”  -Jim Collins


Have you settled for good when you could be great? If this thinking is prevalent in your organization there are three initial things you should focus on to eradicate this mindset.

Identify the source. 

In my opinion, sometimes change is required to eradicate this mindset if it is hard to identify. Hire a consultant. Better yet, engage your front-line staff. They will usually tell you who, what and where the problem is if you just listen to them. Remember, it could be you or someone close to you that is the problem.

Develop a strategic plan.

This is the easy part. Once you have identified the source, work with your core team to put a plan together.  According to an article in the Harvard Business Review by Roger L. Martin there are three basic rules for a successful strategic plan.

  • Rule 1: Keep the strategy statement simple.
  • Rule 2: Recognize that strategy is not about perfection.
  • Rule 3: Make the logic explicit.

Implement the plan. 

This is the hardest part and where most tend to fail since implementation is not just about introduction but also about consistent follow through. Patience and accountability are vitally important in achieving the outcome of your plan during the implementation stage. Depending upon the size and culture of your company, this stage can take some time.

RCM in this new healthcare era requires innovation. Innovation cannot flourish in a culture where excuses are prevalent.

What is an example of a simple strategy statement that companies can use to assist in developing a successful strategic plan to eradicate an excuse-ridden culture?

Pricing transparency: What does it mean for your healthcare service?


Almost every conference that I have attended over the past year has focused on healthcare pricing transparency for the consumer. In my opinion, this dialogue has started to fast track based upon the data that CMS started releasing yearly regarding Medicare payments for Part B providers. While this is just a component regarding pricing and payment, it does not tell the whole story. However, this will continue to be the story that is told unless the healthcare industry takes the lead. Currently, many entities are currently playing defense instead of offense when it comes to pricing transparency.

Many companies, including my own, are working on initiatives to make it easy for the healthcare consumer to have quick access to pricing information, as well as customer service call centers to assist patients with understanding their healthcare benefit for a particular service and the relative out-of-pocket costs.

One area that healthcare entities should focus on is the billing statement or invoice that a consumer receives after their care. This is oftentimes an afterthought. The patient experience is not only regarding the quality of medical care they receive but also the quality of care they receive throughout the revenue cycle process. Your billing statement should follow the three Cs:

A billing statement or invoice should always have a clean look and feel to it. The customer should be able to “see” the invoice without confusion.

The itemization of charges should be clear and understandable. The patient should not have to guess what the charges are or what they were for. You should stay away from using technical terms that require a dictionary to understand. Eliminate the use of acronyms.

The statement or invoice should be brief. The more information the more confusion which ultimately results in a call to your customer service center or lack of payment.

The look, feel and content of your billing statement and invoices could be another reason why the healthcare consumer is confused regarding the services received and the associated charge.

Do you agree that a component of healthcare pricing transparency is relative to the billing statement and invoice? Are there additional points for companies to consider than what is listed?

Is Your Leadership Paradigm Stuck?


Leadership does not develop in a day, it takes a lifetime. It would be fair to say that you are not “born” with these behaviors, they are learned. 
 Last year, I read a profound statement in the book The Servant, by James Hunter:

Our outside work enters our consciousness through the filters of our paradigms.”

Our paradigms are synonymous with our perceptions of how we believe or think things to be.  What if your paradigm as a leader was wrong? What if what you think leadership is, really is not? Paradigm shifts cause us to move outside our comfort zones and force us to do things differently. 

What is leadership? Lee Hoffman has one of the greatest definitions penned to-date:

Leadership is the skill of influencing people to work enthusiastically toward goals identified as being for the common good.”

True leadership is the skill of “influencing” people, not “controlling” people. 
This paradigm shift does not come without sacrifice, because to gain influence with people, you must serve and mentor. Insecurity is the roadblock that causes leaders to lose influence with their staff and resort to power to coerce their staff to perform. 

Two great examples in history of individuals with extreme influence who were not in a position of power are Ghandi and Martin Luther King. Ghandi influenced a movement in India to receive their independence from the British Empire in 1947. Martin Luther King inspired the Civil Rights movement that forever changed America. Neither feat came without tremendous sacrifice from these two leaders, and their influence on the world is recorded in history. 

A leader is someone who identifies and meets the legitimate needs of their people. A leader removes barriers in order to serve the customer. To serve as a leader is not to be enslaved to your organization.

A slave leader meets and identifies the WANTS of the people; a servant leader meets and identifies the NEEDS.” (James Hunter, The Servant)

A leader should never settle for mediocrity or second best. People have a NEED to be pushed and held accountable. It may not always be what they WANT, but a true leader is more focused on the needs of their followers.

I don’t necessarily have to like my players and associates but as the leader I must love them. Love is loyalty, love is teamwork, and love respects the dignity of the individual. This is the strength of any organization.”  -Vince Lombardi

This week I encourage you to explore your paradigm of leadership and what a successful leader is. Write down a list of 5 to 10 attributes that you want in a leader. Do you exemplify these traits?

Are you using these 3 self-pay management strategies?

Self-pay management (SPM) seems to be one of the key topics that is being discussed at every healthcare conference. If you are just beginning to develop strategies around managing your self-pay… great! There are three key points that I believe you’ll want to consider when putting together a SPM strategy:

1. Categorize your self-pay.

It’s important to segment out your self-pay receivables, similar to developing strategies around denials management. For example, in order to discover trends in your self-pay, identify which self-pay accounts are associated with deductibles vs. patient balances from insurance not allowing 100% of your total charges. Once you do this, you can begin to develop specific benchmarks that target patient behaviors in order to increase your self-pay collections.

2. Consider a healthcare scoring solution.

A lot of healthcare companies are throwing ‘good money’ at accounts that are just bad-debt because the debtor has no intention of paying. There are several solutions available today that provide a patient healthcare score to help you target accounts with a higher propensity to pay.

3. Use regionalized collections efforts.

Find those early-out agencies and collection agencies who may collect delinquent accounts for a local hospital, local energy company, or the water company. These agencies already have a current database of debtor information that can assist in collecting on your healthcare debt. In my own experience, our company moved to a regional approach and experienced an increase in our self-pay collections greater than 10% in the first year of implementation.

There are many more advanced strategies that I’ll later discuss to help you continue refining your SPM process. However, consider these three key points vital when analyzing your self-pay. As the saying goes, the definition of insanity is expecting different results when doing the same thing over and over. Don’t let your self-pay management spin you into insanity.


Join The Conversation!

What strategies do you currently use for Self Pay Management? Reply below and let’s discuss what’s working well in your market…