Stone Medical Clinic had much to be proud of—a long history of excellent patient care, well trained physicians, and a growing roster of new patients. What the clinic lacked, however, was profitability comparable to similar-sized practices. While patient volume continued to grow, cash flow faltered as claims payments were slow and as fees under managed care contracts were not keeping pace with costs.
The clinic had recently implemented a real-time, all-payer, Web-based interface to its various payers. As a result, the day-to-day office flow had improved significantly with online verification of coverage and collection of copayments at the time of patient check in. Claims and payments were being reconciled online, resulting in a significant savings in time.
Given concerns related to overall practice financial performance, the clinic's office manager began to analyze claims status and claims history online. It was the first time in the practice's history that all claims from all payers could be viewed in a comprehensive manner.
Getting at the causes
Armed with this new informatics resource, the practice manager began to get at the root causes of lackluster financial performance. For example, she was able to pinpoint excessive claims rejections and the causes for bottlenecks in claims payment with various payers. Conference calls with these payers, during which everyone viewed a common database, resulted in quick resolution for unusually high claims delays and rejections.
At the same time, the practice manager was able to identify the top payers for the practice, providing the information she needed to negotiate more favorable managed care contracts. By demonstrating that the Stone Clinic was a major source of business for certain leading payers, more favorable terms were easy to reconcile.
Using graphic interfaces, the practice manager was also able to create a comprehensive financial report for the physicians, detailing each doctor's claims history with various payers. This information was invaluable in projecting cash flow, setting staffing levels, tweaking treatment plans, and providing a more strategic approach for the growing practice.
While the Stone Clinic is a fictitious practice, its experience is increasingly common. With the advent of all-payer, Web-based portals, physician practices are not only enhancing the efficiency of daily operations, they are also enhancing the strategic management of their practices. Web portals and payer claims processing databases make it is possible for physician practices not only to track every claim each step of the way, but also to access strategic information.
Disparate pieces need a central repository
Just as healthcare providers depend on their ability to review many disparate pieces of patient information to develop an accurate diagnosis and treatment plan, the same is true for the business aspects of managing a healthcare practice. On any given day, a healthcare practice processes hundreds of bits of information related to the business side of the practice, from verifying coverage to collecting copayments. When this information is concentrated in a database format, a whole new world of analytical possibilities is created.