#203 She Never Missed a Monday. Her Collections Dropped Anyway

She never missed a Monday. Twelve months of weekly billing meetings, every number reviewed, every question answered. And by the end of that year her net collection rate had dropped four points, her ninety-plus AR was up forty percent, and her denial rate had climbed from six percent to eleven. The numbers were there every week. The report was accurate. Nothing changed, because the meeting was structured around reporting instead of around deciding. 

System 1: the financial snapshot. Three numbers, charges, payments posted, and unlocked encounters, each compared to last week and month to date. Payments lag charges by 30 to 45 days, so a strong week reflects submissions from a month ago. And unlocked encounters, the number most owners skip, is the most controllable revenue lever on the report. On a practice doing $350,000 a month, each day of unsigned encounters at scale represents roughly $12,000 to $18,000 in claims that are not in the pipeline. 

System 2: AR aging, denials, and stuck claims. AR aging by date of service is the patient-facing view. AR aging by claim date is the payer-facing view. The comparison between them is its own diagnostic: if date-of-service aging is older, you had a submission delay. If claim-date aging is drifting past 90 while date-of-service aging sits at 30 to 60, the payer is holding claims that went out promptly. Denials and rejections are also not the same problem: a rejection happens before adjudication and is a front-end fix, a denial happens after and carries appeal deadlines. 

System 3: the accountability layer. Patient statements, four trackers, the rolling action item tracker, and the onshore manager review. The rolling tracker is the section that makes the meeting matter: eight fields, every item with one named owner and one due date, no item closed without a resolution note. Without it, the same problems get identified week after week and the meeting becomes a theater of accountability rather than a mechanism for it. 

THE WEEKLY MEETING AGENDA 

Financial Snapshot, 5 min. Charges, payments posted, unlocked encounters vs last week and MTD.
Ask: did we move in the right direction and do we know why? 

AR Aging by DOS, 5 min. 

Ask: is the 90-plus bucket growing or shrinking week over week? 

AR Aging by Claim Date, 3 min. 

Ask: where are claims stalling after submission and which payer is holding them? 

Denial Analysis, 7 min. 

Ask: what is the root cause of the top denial and what closes it? 

Rejection Analysis, 5 min. 

Ask: what front-end information gap is generating these and who fixes it? 

PM System Status, 3 min. 

Ask: what is sitting in a status that should have moved by now? 

Patient Statements, 3 min. 

Ask: are we sending on schedule and is patient AR moving? 

Tracker Updates, 5 min. 

Ask: what is still open from last week and does it have a new owner or date? 

Rolling Action Items, 5 min. 

Ask: does every open item have one owner and one due date? 

Manager Review, 4 min. 

Ask: what is the team seeing that is not captured in the numbers?

READING YOUR AR 

90-plus growing week over week. Claims aging without resolution. Ask which payer and what status, and whether this is a follow-up gap or a payer dispute. 

0 to 30 growing faster than payments. Strong submission, lagging cash. Ask whether this is normal lag or a specific payer slowing down. 

120-plus unchanged for 3 or more weeks. Approaching or past timely filing. Ask which claims, what the appeal status is, and whether any need to be written off. 

Claim date aging older than DOS aging. Submission delay. Ask what caused it and whether it is still happening on current claims. 

Unlocked encounters climbing. Charts are not being signed. Ask which providers, how many days open, and who is following up today. 

THREE ACTIONS THIS WEEK 

1. Pull your unlocked encounter count today and bring it to Monday. If it is growing, that is the first conversation before any other section gets opened. 

2. Ask your billing manager for the rolling action item tracker from the last four meetings. If it does not exist, that is the answer. 

3. Write one specific question for each of the three main sections before your next meeting, and notice what changes when the meeting has a questioner in it. 

EPISODE BREAKDOWN 

She never missed a Monday | Reporting versus deciding | The financial snapshot | Unlocked encounters | AR aging, two views | Denials versus rejections | Claims status | Trackers and patient statements | The rolling action item tracker | The manager review | Three things to do this week

Resources block 

1. FREE: Practice Financial Health Dashboard, https://eligibility.natrevmd.com/free-practice-financial-health-dashboard-for-physicians-natrevmd 

2. FREE: Practice Revenue Leak Scorecard, https://eligibility.natrevmd.com/nrm-revenue-scorecard-v3 

3. Everything else we have built, in one place: https://natrevmd.com/trusted-resources/ 

4. Related listening, EP200 and EP201 on building the billing partnership and the shared operating model: EP200 and EP201

Transcript

SPEAKER_00 0:04

If you've been meeting with your billing team every single week for the last year and yet your billing metrics still haven't changed, this week we're going to talk all about what a billing meeting truly needs to have, and more importantly, the actions that have to go along with those billing meetings so that your metrics truly move. Welcome to Nat RevMD, a podcast where we share tips on optimizing medical billing and improving practice efficiency so you can have the business of your dreams. I'm your host, Dr. Heather Signorelli, founder of Nat RevMD. Let's get started. All right, so I do want to share a story. So we have a practice that we were recently meeting with. They were meeting every single week to go over their billing metrics, teams issues, but yet their AR over 90 days was well above 40%. Their denials were high, they had eligibility issues. And at the end of the day, their net collection rate was only 80%, well off the mark of where they should be. And they were trying to figure out why. So today we're going to talk about the issues that happen when you're talking about the wrong things in a billing meeting and the downstream impact of when those billing meetings don't actually result in different actions in order to drive metric change. So hopefully this week we can help share with you guys how we structure our billing meetings. We actually have a structured format that we require to be filled out from the frontline billing teams that then is reviewed by a senior executive and then they execute that same meeting template every single week for every single account. And that happens over and over again. And more importantly, it's not just tracking the metrics, but it's also actually making sure that the actions or the tasks that are then created are actually completed every single week. So you actually start to move the needle. And really, really important that you not only have these meetings, but that you're talking about the right things and that somebody is accountable for the actions after, not just some general, okay, we've got to make sure we're touching the claims more often, or we've got to make sure that we are resubmitting those claims. General comments don't result in measurable, actionable results that improve your revenue. So those are going to be the really key things that I want you guys to take away this week. And so today we're going to get very, very tactical on making sure that it is you calling out a specific individual who's going to be taking that task. And obviously, if your billing is in-house, this may truly be you. It may be your office manager, maybe a COO. If you are struggling with that level of strategic direction and you're needing that, hopefully this helps. If you use an outsourced team, hopefully they are using the same framework. But if you're seeing your metrics over and over again not improve, this may be a gap that that team is really struggling with. And either they need to be able to fill in that gap and make sure that the gaps that you're seeing in your billing team are actually getting resolved, or that team may not be the best fit for you. Obviously, metrics and what to measure is very important. So we do have a quick link in the show notes related to what metrics you should be following and a download of a quick tool you can use if you need help kind of structuring where your metrics can start. So first we're going to talk about the financials, the financial snapshot that needs to happen every single week. And again, this is not an executive level meeting. This is a billing meeting that occurs between your billing staff. So if you're listening to this and you have an outsourced team, this is what you hope that they are doing. And you can ask questions if you're doing an RFP, trying to find a new biller. These are the questions to ask about how they structure this so that you know if things are truly going to get done the way that they need to. And just like if you're running a practice or hospital, you have daily huddles with your team and then weekly executive meetings to understand, okay, where are our metrics? What tasks or projects are in progress, what things have rolled off and are completed, what things do we need to add. All of those things are what make a practice run smoothly, whether that's in your financial office, your front desk, your clinical team. Wherever you have humans working, you need to be able to measure measure metrics and then be able to set up processes of things that are working well and need to be communicated across as closed projects or things that aren't working well. And then you create new projects and assign them to individuals with timelines so that you can consistently have measurable progress and improvement in your metrics week after week so that you're not looking at the end of the year going, huh, I wonder why my net collection rate is 80%, where it should be 95%. So hopefully you guys are already measuring metrics. So this is not a new thing. But the first section of a weekly billing meeting is to go over metrics. And this is the fastest way to know if things are moving in the right direction from a week to week perspective. And so these are typically several different numbers, but first it's going to be charges, payments posted, and unlocked or unbilled claims. So these allow you to track is there a dip? If there is a dip, why? And can we get it fixed quickly? So charges obviously are the amount of build charges that go out every single week. Is the team on time? Are they caught up to the current service date? If they are behind, why are they behind and who's doing something about it? Are you caught up on payment payments being posted? So as those payments come in to your bank, you want to make sure that those are posted in the practice management system. If there's many any missing ERAs, missing checks, those things all need to be communicated within this billing meeting. Obviously, from here, getting that information to the practice is really critical. If it's an in-house team, they need to be working with the right individuals to get those addressed. If it's an outsourced team, they need to be getting this information to their transit, you know, their weekly meeting with the practice, or alternatively, communicating that through an email or through a tracker, depending on how you manage things. So the last is going to be unlocked encounters or unbuilded claims. So you want to understand if there's unbilled claims, why? If it's because the physician hasn't signed them out and locked them and coded them, then that unlocked encounters needs to get over to the right team so that those get caught up and addressed. Highly recommend that you create a policy around what good looks like. So for us, we're getting those charges and payments posted on a daily basis with ideally, you know, completion within 24 to 48 hours of when those charges or payments came through. And with unlocked encounters, we're typically sending those reports to the practice to address, but we really encourage practices to have a policy around do they sign those out within 48 hours or 72 hours of when the note or when the patient was seen? And having that set is a policy that everybody adheres to. And we even have some practices that create dashboards around that. They create metrics. If the physician is hasn't signed out their chart, they will withhold pay until they get caught up. Because at the end of the day, if you have a major problem with uh chart sign out, you've got to get that fixed in order for revenue to get fixed. So in the billing meeting, all of these metrics are compared to the same week or same time point in the last week. So you're always kind of looking at a seven-day period just every single week, and then you're comparing that number to the last. So if charges went up, maybe patient volumes went up, or if charges went down, maybe a physician was out of the office, or maybe unlocked encounters has spiked up. Again, your idea or the goal here is really to track and trend trends so that you catch that before months end. So one of the mistakes that we often see is that practices really aren't, they don't have anybody who's looking at this at a weekly basis. So when it gets to month end and there was a huge spike in unlocked encounters, that now you have 40, 50, 100 of those just sitting there for a specific physician, then that it's it's it's almost too late. Not too late, you can't ever fix it. Obviously, you can, but it's too late to fix that month's receipts issue. And so these are our leading indicators of what's going to happen at month's end if we start to track these week after week. Charges obviously are really critical from a revenue perspective. So charges drop, revenue is going to drop. And typically that lags about 30 days. So if you have lower charges in June, your receipts in June may still be okay, but your receipts in July and maybe even August are going to be lower. And so, really important from a financial perspective for you to track and trend this, because if you do see charges dropping, that then you need to be thinking about is there an issue that I need to correct? Is there a physician that has unlocked encounters that I can address? Is there a payer that has denial issues? And we'll talk about AR here in a minute, but really tracking and trending those so that somebody can raise the flag before it gets too late and then you're stretched with payroll. So, really important to have these things tracked and trended. All right. So the next area that you want to talk through is AR aging, things like denials, basically where are claims stuck? So obviously on a weekly basis, your billing team should be meeting together to figure out where are their major issues with claims that are getting stuck. Is it a payer issue? Is it a specific denial code that keeps getting reported? Is it eligibility issues that we need to get back to the front desk? Is it coding issues? Is it a new bundled rule? Is it a credentialing issue? Again, all of those things need to be discussed and not just silently, oh, there's another eligibility denial and trying to just flip it to the front desk. The goal here is really within the billing team to understand what's happening and why so that you can fix it and address it. So sometimes that may be was there an AR person who was out this week? Okay, well, we've got to get that caught up. And what are we going to be doing over the weekend to address that? And how can we make sure that we are on track for looking at claims every 21 to 30 days, identifying claims that are, say, unresolved after the second resubmission. And that's a big one, especially if you have a complex practice. So there are some subspecialties that are a little bit more complex when it comes to denials. We have a lot of OB practices, we have an allergy practice, we have uh surgical subspecialties where the denials can get challenging. And because of that, the frontline billing staff may be trying to address it and maybe one resubmission, and maybe it was a change of uh a code or resubmission of medical records. But if it the denials keep happening, so you have the same claim and it's denied not just once but twice and getting unresolved answers, then that needs to be escalated to a higher level strategic person within the billing team. So sometimes that's somebody with a little bit more seniority, sometimes that's a certified coder, sometimes that's an individual who can really understand more complicated denials. This is where when we take over practices, we see a lot of AR issues, is because they just keep statusing the claim. They call the insurance company, they just get a response back saying, here's what's wrong with the claim, but then they don't have anybody who's knowledgeable enough in order to resolve the claim. And so those are things that can be talked about in the weekly billing meeting because then you can flag, okay, I've got these five claims. We resubmitted them once. Obviously, you know, didn't address the issue. We're still having a different denial, or maybe it's the same denial, but we still can't get the claim paid. Who can we discuss with to get this addressed? And so that's where those senior level billing team members are meeting, understanding those claim issues, and then getting those dealt with so that then they are paid and finally get money in your account, which is the goal here. So again, we're tracking and trending this on a weekly basis so that you're identifying those issues, not at the end of month, but every single week, so that at the end of the month, your AR numbers still look good. At the end of the month, your receipts look like what you expect. And that's a really, really important thing for you to make sure that you have this in order so that you're not surprised at month end. And again, if you're listening and you're the physician owner, you don't necessarily need to be hearing all of this level of detail unless you're not getting the results you want, obviously from your billing team. But if they are not having this level of detailed conversation internally, this is where problems can creep up. Obviously, the next part of this is really, okay, now how do I take this information and create action plans that then actually get acted on? And the the third part of this process is then really actually creating project plans around, okay, we're gonna have a senior level billing individual who's gonna sit with the practice or with the coding team or with the billing team and go through those complex denials. Maybe they're doing that in this weekly meeting live, which is a great best practice, but that is then a who, what, when, and where. So who's gonna sit there and do it? When is it going to happen? How, you know, is this gonna occur on a meeting, or is that are they gonna do it offline and then meet together with the results? And then who is ultimately responsible and accountable for the action that needs to occur? So an example of this is okay, we've got some complex denials. We need to review those with the coder. We get those reviewed, we get them approved by the practice because, say, the practice needs to weigh in on any coding issues or changes that we need to make sure that we're all aligned on, that all gets resubmitted and that all happens, you know, that week. It doesn't happen at months and for claims that are two, three months old. It's happening as those, as those claims are addressed on a weekly basis within the meeting. And again, the key here is who is truly acting, who is truly going to be responsible for those actions and is it written down? So in our weekly billing meeting template, we start with the metrics, right? The charges, payments, unsigned accounts, right? So tracking that on a on a week-to-week basis, trending that from the week prior and making sure that we're on track to hit the typical average from a month-end perspective. Then we're talking about the specific issues, like we talked about with AR, with payment posting, with claims, basically anything that needs somebody's attention to. And then the last section of the meeting notes for the weekly meeting is okay, now what projects are we going to put into action? What's the timeline for those to get completed? And then who's actually responsible for making sure that those things happen? Ultimately for us, our account managers are responsible for that. And they are in the accounts every single day. So these are not account managers with, you know, 20 different accounts. They are account managers with a handful of clients who then they are in the accounts auditing, working with the billing team, solving complex issues, getting those metrics exactly where they need to be. We were looking at months end for our company and all of our AR over 90 days was all in the green. And that's because we have this almost OCD process around looking at the metrics on a weekly basis, meeting with those billing teams, doing those huddles so that these issues are getting to the practice, they're getting resolved, and then getting really, you know, measured and monitored. Because again, what you don't measure is not going to be something that improves over time. So, really, really critical that you have these three parts down for your internal billing meetings. So if you have an in-house team and they are not doing these, identify who can take charge of this and do that this week and set up these huddle billing meetings on a weekly basis and go through this. Obviously, that doesn't mean that they shouldn't be talking all week long. We manage our company through Microsoft Teams. And so the team's messages are blowing up every day, all day long on everything so that they're coordinating really the care of the practice every single day, all day long. But this allows the billing meeting, allows them to have a more structured approach to metrics, problems that need to be resolved, and then action items or projects that need to be started in order to manage the account. So, really, really critical that if you don't have this in place or if you don't have the bandwidth to do that in place, that you identify a resource who can, whether that's an additional in-house team member who you need to hire, or alternatively, another outsourced billing partner. Again, we do have in our show notes some metric information. So if you don't have any metrics today or you don't even know what metrics you should be measuring, it's a great place to start. So head on over to the show notes and you can download that resource. We are also going to be doing an EM coding webinar on August 26th, I believe. And one of our CPC educators, so coding educators, is coming to do that course. I'm really excited about this new webinar series that we're going to be doing every single month. I think this is going to be a huge resource for practices so that you guys get the information you need. They will be recorded. So please head on over to the show notes and we can share that link for registration there. So great two different resources for folks to use. And as always, if you are looking for a new billing team, we'd love to chat with you. So head on over to natrevmd.com. Up in the right hand corner, there's a free metric audit. We're happy to sit with you and go over your metrics where you're at. Um, we've met with practices in the past where the metrics look great and they've got everything that they need. And it's just another independent set of eyes that can give you that validation. If for some reason something's off, we can share if we're able to help or if we may be the right fit for your team. So again, really, really critical to input, really, really critical to implement these weekly billing meetings with your billing teams. Again, whether they're in-house or outsourced, they need to be having these conversations. But hopefully this helps uh you structure your team and think about ways that you can continue to improve your metrics. All right, have a great rest of your weekend.