CMS Connect Login:

Login Assistance

Optimizing a Physician Practice

How to respond to the increased shift in patients’ financial responsibility
By Gail Wilkening

As more financial responsibility is rapidly shifted to consumers, physician offices must respond quickly with changes to workflows, policies and procedures, patient expectations, and accountability standards. Not assessing your practice for outdated processes is not an option anymore. Even if the key performance indicators (KPIs) are within the best practices range, you still need to implement changes so that KPIs remain in the same acceptable range.

If you have not made significant changes to your processes, begin with an assessment. The results can be surprising. When data is collected and analyzed, we often find that processes are not as tight as presumed. We may discover that workflows often miss key tasks and thus create unnecessary financial risks. Here are key operational assessment components.

Registration for New Patients

When scheduling a new patient appointment, is staff entering a “mini-registration” with basic demographic information? Or is the complete registration information entered, including insurance? If performing “mini-registration,” the patient should be contacted prior to the appointment to complete full registration for insurance verification.

Robust Insurance Verification

Does staff have a tool to efficiently verify insurance for patients? Such tools vary greatly as do workflow designs for insurance verification. A simple verification indicating the patient has active insurance, at the very least, will confirm the insured’s status and that information added to registration is accurate and can be identified by the payer. More in-depth verification will identify copayments for visits. In today’s market, it is necessary to identify deductible amounts and to know if the patient’s yearly deductible has been met. Detailed workflows and staff compliance are essential to efficient revenue cycle management. If your vendor offers batch verification, sending files two to four days early will allow staff to contact patients who fail eligibility prior to the appointment, and provide sufficient time to revalidate the new insurance.

Validating Insurance Verification

How many eligibility denials does your practice receive per month? What are the demographics? The denial rate is a great barometer of the effectiveness of the verification system. Check your clearinghouse for information to identify the number of claims requiring cleanup after submission. It is also good to know how many claims per month are denied for authorization or referral issues. If insurance is not valid in the practice management system, how is staff able to identify referral needs?

Point of Service Collections

These days, 98% of all copays should be collected at the time of service. The practice workflow should include a protocol for staff to discuss and collect outstanding balances before the appointment. Attempts can begin when the patient calls to schedule an appointment, when the appointment is confirmed, and at check-in. Front desk staff, financial counselors and practice administrators must all follow the same protocols.

What tools are in place for the front desk to easily identify outstanding balances? Staff need training to effectively communicate with patients who are not willing or able to pay. Management tools should also be in place to determine the overall percentage of copays and outstanding balances being collected. A simple log at the front desk can measure success.

As a rule, patients should be required to pay some or all of their unmet deductible (contracts permitting) and coinsurance prior to receiving non-emergency procedures. Uninsured patients can be reminded when an appointment is scheduled that payment in full is expected on the date of service. Again, staff must be well-informed and have tools on hand to correctly communicate with patients.

Pre-Collection Process

How much does your collection process cost? A study of a large physician practice found that over $18,000 per month was being spent on collecting outstanding patient balances. When making collection calls to patients, 67% of calls were not answered, resulting in staff leaving voice mail. The collection process was redesigned to include technology to collect more dollars upfront. These changes alone saved the practice over $9,000 per month.


Is staff up to date on recent health care system changes that are affecting operations? Patients often do not understand their health care plans or why they are responsible for higher copays than in the past. A well-trained staff will effectively communicate and educate patients. A practice is more likely to successfully collect from patients who are informed about their benefits.

Gail Wilkening is a senior health care consultant at PBC Advisors, LLC, located in Oak Brook. PBC Advisors provides business and management consulting and accounting services to physician practices. For more information visit

Document Actions

Join CMS

Why join?  The Chicago Medical Society offers many benefits, including career placement, advocacy, networking, and member to member collaboration. Click here to explore all the benefits of membership.

CMS Connect

CMS Connect is an exclusive community that allows members to discuss the issues impacting their practices today. Visit CMS Connect today.