Here’s what you know: How you handle your billing directly impacts your bottom line and you should consistently find ways to improve it for growth.

Here’s what you might not know: To assess the success of your billing operations, look at how you handle these 4 key tasks:

1. Claim Submission
2. ERA Processing
3. Denial Management
4. Financial Insights

If you’re practice already has intentional ways to handle these processes, great. If not, we have a little work to do. But whether you’re already managing these tasks or not, let’s go back to what you know: you should consistently find ways to improve it for growth.

So, let’s review these tasks and the different ways they can best be handled by growing medical practices.

Claim Submission

Claim submission is the process of submitting claims to insurance payers for financial reimbursement. Basically, it’s how you get paid for the services you provide. But more than that, the claim submission process directly impacts financial stability, ultimately affecting practice operations and patient care.

If there are severe bottlenecks in how a practice submits claims (incorrect information, mission documentation, coding errors, slow submission, etc.), then they’re likely to see frequent denials. And, as we all know, claim denials = bad. Receiving a denied claim means you now must correct and resubmit the claim to get reviewed for reimbursement…again. This not only delays cash flow, but studies show that up to 60% of denied claims are never resubmitted for reimbursement, meaning many practices like yours are losing hard-earned money.  

Luckily, there are many ways to submit claims, some offering more efficiency than others.

Without PMS

PMS stands for Practice Management Software. Most medical practices use a PMS or an electronic health record (EHR), which serves the same purpose, to manage patient information. If your practice doesn’t use one of these software systems, or if it does use one but the software lacks billing capabilities, then you are likely submitting claims manually through each individual payer portal. If this is the case, you already know how time-consuming and error-prone this process can be, so I’ll spare you a detailed reminder.

With PMS

With a PMS, the process is still manual; however, it is done through one portal instead of each individual payer portal. You’ll still need to manually prepare each claim, but then can submit them in batches to payers through one software. In addition to not having to jump between payer portals, you get the added benefit of having all claim information in one place. Since this is still a hands-on process, it’s usually used in tandem with a qualified in-house biller, automated billing, or an outsourced RCM team.

With PMS + Automated Billing

When you add automated billing to your PMS, the software will automatically scrub (review and edit) and submit batch claims daily, taking out the manual work. Many small practice owners without a dedicated billing team find this to be incredibly helpful when it comes to managing their workload.

With PMS + RCM Team

And last but not least, using a PMS with a revenue cycle management (RCM) team. Similar to automated billing, claims are submitted without manual work on your end. However, with an RCM team, you get added benefits:

• Automatic batch submission twice a day, allowing for faster payment turnaround time on claims submitted earlier.
• A dedicated team you can chat with about your current claim statuses, billing concerns, etc. It’s essentially like hiring a team of billers, without the time, energy, or training.

ERA Processing

First, what is an ERA? Electronic Remittance Advice (ERA) is essentially a digital explanation of benefits (EOB) sent by the insurance company to your practice. It details how they processed a specific claim you submitted, including payment details and remaining patient balances.

ERA processing is the process of handling those electronic notifications. In other words, posting them in your system as paid, denied, adjusted, etc., to keep a digital record of outstanding claims and balances.

Without PMS/EHR

Since ERA Processing is an electronic process, you can’t exactly handle this task without a PMS, EHR, or some type of billing software. Without a PMS, you’re most likely manually tracking claim statuses and patient balances through payer portals and documenting them via Excel sheets. Or receiving paper remittance advice in the mail, and trying to keep them organized that way. If that’s what you’re currently limited to, then something is better than nothing (since you need a way to track this information). However, implementing technology is going to be your best bet for handling ERA processing with better accuracy and ease.

With PMS

With a PMS, you can receive ERAs directly in your software, then process/post that information in the same system. It makes for an incredibly easy and seamless process, saving you the time and disorganization of jumping from paper to multiple systems.

With PMS + Automated Billing

When you add automated billing, this process happens automatically for specific codes, such as CO-45 for a write-off or PR-1 for patient responsibility. When there are no manual adjustments required for the claim, the system handles the standard posting, freeing you to focus on the items that need your attention.

With PMS + RCM Team

Easier becomes easiest when adding an RCM team to do the heavy lifting. An RCM team takes full responsibility for processing ERAs. They’ll post payments, identify denied claims, and even handle aspects of denial management.

Denial Management

We talked about the impact denied claims can have on your practice. So, naturally, claim denial management is incredibly important. Claim denial management is the entire process of identifying, understanding, and resolving denied medical claims. Once receiving an ERA with an explanation for the denial, it’s the practice’s responsibility to correct and resubmit that claim for reimbursement (in most cases). The efficiency of this process overall becomes exceptionally important if your claim submission process needs work, causing your practice to regularly see denied claims.

Without PMS

Without software, we’re back to the manual processes. This means you’ll need to manually review every denial notice, decipher the reason for denial, correct any errors, and resubmit the claim – for every payer portal.

With PMS

A PMS won’t magically fix denied claims, but it will help you identify them, all from one software. You’ll still need to correct and resubmit denials, but you’ll be able to do so in a fraction of the time by having information like the ERAs more accessible. Plus, being able to submit batch claims directly from the same software. The same goes for when you add automated billing.

With PMS + RCM Team

When you add an RCM team, they take the lead on denial management. They’ll analyze denials, identify the root cause, work with you to correct errors, and resubmit claims for reimbursement. You may be asked for additional information to support the resubmission. However, it is a far less hands-on experience.

Financial Insights

You’ve done all this hard work to ensure a smooth revenue cycle; now, let’s make sure it pays off. Monitoring your practice’s financial insights will offer transparency into what’s working and what’s not, allowing you to address issues before they become detrimental to your practice.

What are financial insights? They’re billing reports that demonstrate the performance of different billing areas, such as the percentage of claims paid, reimbursement speed, aging accounts receivable over 90 days, etc. Monitoring these reports isn’t difficult once they’re accessible to you, and there are a couple of ways that can happen.

Without PMS

In order to generate billing reports, the software needs to gather information from the billing and patient data stored in the system. Since a PMS serves as a central platform for this data, generating comprehensive reports is simple. However, achieving the same level of efficiency using Excel or paper-based methods isn’t likely. So, without a PMS, you likely have limited financial insights.

With PMS

With a PMS, you will have access to standard reports that retrieve data from the system to offer insights into billing, as well as any other practice performance information it can provide. The same applies when you integrate automated billing.

With PMS + RCM Team

RCM services provide comprehensive reports with key performance indicators (KPIs) that go beyond standard billing metrics. These reports can help you identify areas for improvement and make data-driven decisions about your practice’s financial health, including custom recommendations from a team of revenue cycle billing experts.

PMS, Automated Billing Software, and RCM Services

We’ve talked a lot about practice management software (PMS), and automated billing as a helpful add-on. However, note that we’re unable to speak to how other software might work. So, while these features may be available to you via Therapy Brands’ billing solutions, we can’t assume the same is true universally.

If you’re interested in adopting a PMS or switching to a PMS with better billing capabilities, schedule a demo to see our solutions in action.

Interested in learning more about implementing revenue cycle management (RCM) services? Schedule a free billing consultation with our team. Not only can you ask questions and learn more about the service, but we’ll also provide a complimentary analysis of your current billing processes and KPIs.

Key Take Away

When determining how you should handle these billing tasks, use your discretion to choose the option best for your practice. If you’re a larger practice with 5000+ monthly claims, leveraging an RCM team can offer a lot of benefits such as immediate access to qualified billing assistance, without hiring and training new or additional billing staff. However, if you’re a small to medium practice with a part-time billing employee, levering a PMS with automated billing can significantly improve staff efficiency. Whichever route you choose, make sure to regularly perform these tasks, adjusting as needed along the way to fast-track practice growth.

Billing Tasks Comparison

Without PMS	Without PMS	With PMS	With PMS + Automated Billing	With PMS + RCM
Claim Submission	Manually submit claims through individual payer portals.	Submit claims in batches through one software platform.	The software automatically submits batch claims once a day.	The software + RCM team automatically submits batch claims twice a day.
ERA Processing	None	Receive and post ERA information in the software.	Receive and post ERA information in the software, with automatic processing for specific codes.	RCM team handles ERA processing.
Denial Management	Manually track, research, and fix claim denials through each payer portal.	Track, research, and fix claim denials through one software.	Track, research, and fix claim denials through one software.	RCM team handles claim denials with your guidance.
Financial Insights	None	Get standard billing reports based on PMS data.	Get standard billing reports based on PMS data.	Get enhanced reports, including KPIs for practice performance and financial health.