business of pediatrics

How In the World to Get Paid: AR & Billing for Pediatricians

Billing and AR are two parts of a revenue cycle that keeps your pediatric practice going strong. Concerns over the COVID-19 pandemic and other long-standing AR issues have pediatricians wondering how in the world to get paid for their services. We asked billing experts Lynne Gratton, Jan Blanchard, and Heidi Chamberlin for their advice, and they delivered.

In May 2020, Lynne Gratton, CPPM and Jan Blanchard, CPC, CPEDC, CPMA of PCC and Heidi Chamberlin of PedsOne pediatric billing hosted A/R Collection Strategies, an online course that was a part of PCC’s first virtual Users’ Conference. This post draws on the expertise shared in that interactive course. You can find the full course recording here or view it below:

Opportunities in Telemedicine

“It’s frustrating to hear that there’s no silver bullet that’s going to get you paid,” says Jan, but that doesn’t mean you should give up -- Jan, Lynne, and Heidi, of PCC and PedsOne pediatric billing respectively, have plenty of ways to help.

Many practices switched to telemedicine -- some of them extremely quickly -- to offer care to patients when the COVID-19 pandemic meant many states required families to stay at home. During the public health emergency, many payors were required to pay for telemedicine services on par with in-office visits (e.g., a 99213 would be paid the same whether in-person or via audio-visual telemedicine).

As the pandemic develops, it will be important for many practices to keep telemedicine paid in parity if it is to continue as a viable business choice. There is no certainty yet on whether that will be the case, as the decision rests with individual state legislators. For more information on what your state’s telehealth legislation looks like, visit The Center for Connected Health Policy. For now, however, practices can still find opportunities in telemedicine.

Credit Card on File Policy

For example, a credit card on file policy can make it easier for parents and practices to send and receive payment. Heidi explains that paper bills just aren’t as effective as they add work for staff and postage charges: “It’s going to cost more money at the end of the day, for a copay you could have collected at the beginning of the office [visit].” 

Lynne also adds that credit cards on file are touchless, and a safer form of contact-less payment for patients who may prefer to err on the side of caution. Lynne advises practices that credit cards should not be stored physically, but in a secure, encrypted place from a trusted vendor. She explains, “The credit card on file is a credit card the practice would store so they can pay off a balance the insurance does not cover, like deductible or coinsurance. That credit card should be stored in a secure online bank or merchant services account.”

Next-Day Follow Up

Calling back the day after a telemedicine appointment can give your practice essential information on how well telemedicine is working for your patients, give an opportunity for questions missed during the visit, and “gives [staff] another touch point with the patient to discuss balances and copays,” says Jan. “Patients have been receptive to this, and it’s really good PR.”

Practices short on time can narrow their call lists to those with open balances, complex cases, or another factor of their choice. Next-day follow up doesn’t have to be a permanent change, but could be useful as a trial period tool to ask questions such as, “How was the visit? Did you have any trouble getting into the appointment? What could we do better?”

Lynne suggests that practices could also use other routine calls for collecting outstanding balances, such as when scheduling appointments. For patients having trouble making payments, the experts recommend solutions such as setting up a payment plan early, asking for a partial payment at TOS, and even suggesting a credit card especially for medical expenses.

Save Money by Challenging Claims

A healthy revenue cycle is arguably as much about saving money as it is about earning it. One enormous area in the cycle that could save your practice the revenue it’s earned is not in copays or TOS payments, but in timely, accurate, and fair insurance payments.

“One loophole is the idea that [insurance companies] can pay in a timely fashion, but then recoup the money and hope that you never argue the recoupment,” Jan explains. “So they’re skirting prompt pay laws by paying what you’re due… only for them to take perfectly legitimate payments back again.”

Practice Due Diligence

The experts advise practices to check their state recoupment laws before doing anything else, to be sure you understand exactly what the law allows -- Pennsylvania allows an appeal up to 12 months after the date of recoupment, for example, while California’s is 12 months from the date of service. 

Heidi also stresses that practices double check a recoupment or takeback’s reasoning -- sometimes an insurance company will claim the patient was ineligible at the time of service, but this can be easily proven. She says that she has also had success arguing that while a secondary’s timely filing date may have passed, the primary’s timely filing date was submitted on time: “It sounds like they wouldn’t pay it,” Heidi says, “But they will!”

Always question the insurance company,” agrees Lynne.

Be Your Own Advocate -- And Be Aware of Your Allies

Whether your practice has an in-house biller or you outsource your billing to a vendor, you can have a powerful effect on paid claims and fair payment practices when you know your state laws, your rights to appeal, and the allies in your corner.

For practices with in-house billers, it’s crucial for everyone to work together as a team so that claims go out on their best foot and are appealed and questioned when necessary. PedsOne has a collection of billing best practices to help you. Communication between billers, office managers, and physicians keeps expectations clear and can help your practice be agile in getting payments, setting smart prices, and saving you (and your patients) money.

Call Your Provider Representative

Provider representatives aren’t always available at every insurance company, but you should be sure to find out if your payors have one available, and if so, use their services when dealing with a particularly difficult issue or if you’ve gone back and forth over a claim three or more times, according to Heidi.

“The other option if you’re getting the run-around a lot is to use your local AAP chapter,” she adds. “Because they can go to bat for you on things that aren’t getting paid that should be paid.” Local chapters’ work can be added to national advocacy for broad change, such as the May 2020 Payer Advocacy Advisory Committee’s report on conversations with major payors to continue telehealth payment parity.

Jan agrees, and says that in addition to your local chapter, you can call upon the Private Payor Advocacy Group, which is a national-level group that exists solely for the purpose of negotiating with insurance companies, and can make them aware of widespread problems. This group offers resources such as appeal letter templates, hassle factor forms, and example letters to carriers. 

Another resource is your state’s Banking and Insurance Commissioner. “Sometimes all it takes is cc’ing them on an appeal or letter of request. That gets attention, and if it doesn’t, you can follow up with that commissioner.” Find the full directory of State Commissioners here.

Why Your Revenue Cycle is Worth Fighting For

If you’re a physician or office manager, there are many tasks for you to focus on, and only one of them is your billing. The expertise of coding, billing, and appeals experts like those at PedsOne and PCC can guide you when you want to appeal a decision, make smart billing decisions, or simply want to double check you’re getting the revenue you’ve earned.

When you’re proactive and agile, your revenue cycle helps your practice grow and change as payor’s policies do, and helps policymakers and payors alike understand the valuable work pediatricians do, making you -- not the insurer -- the agent of change.

For lots more advice and information from Heidi, Lynne, and Jan, be sure to check out their entire Users’ Conference course, “A/R and Billing Strategies”, which like all of our UC2020 courses is free and open for you to visit whenever you’d like. Visit the course directory here for the full list of courses.

Visit the UC2020 course directory!

Allie Squires

Allie Squires is PCC's Marketing Content Writer and a transplant from upstate New York. She holds a master's in Professional Writing from NYU.