Live Call March 30, 2026 - Mastering the Revenue Cycle

Clinical Business Framework Live Call March 30, 2026

Insurance Coverage and Management Updates

Jennie discussed insurance coverage variations across different providers, noting that Humana and United Advantage cover certain services at 100%, while Blue Cross Advantage plans have inconsistent coverage. She mentioned that about 85% of patients are eligible for chronic care management, which requires documentation of time in 20-minute increments. The group welcomed Charu, an internal medicine physician from Austin who recently opened a private practice, and discussed the revenue cycle management process with Vineka, a psychiatrist from Utah.

Healthcare Billing Error Prevention Strategies

Jennie discussed common error points in healthcare billing processes, highlighting areas such as patient registration, documentation, coding, claim submission, and accounts receivable management. She emphasized the importance of timely filing, claim scrubbing, and preventing denials by identifying patterns and addressing upstream issues. Jennie also stressed the need for effective clinical documentation to mitigate audit risks and the increasing use of AI in down-coding medical claims. The discussion touched on strategies for managing accounts receivable, aiming to keep the majority of claims within a 40-day cycle and improving collection processes for patient responsibility.

Billing Process Challenges Discussion

Jennie, Charu, and Vineka discussed billing processes and challenges. Charu explained that her practice has a $100 threshold for automatic billing, while Vineka described their use of credit cards on file with some automation issues. Charu shared difficulties with weight management patients who pay cash but receive insurance-related billing links, and mentioned she needs to learn how to run reports and understand KPIs through Athena's system. Jennie emphasized the importance of becoming educated consumers in billing processes and outlined action items including checking insurance eligibility, posting payments daily, and monitoring AR aging on a weekly basis.

TMS Treatment Management Discussion

Jennie and Vineka discussed tracking and managing TMS (Transcranial Magnetic Stimulation) treatments, including varying insurance authorization periods and the use of a TMS sheet to monitor progress. Vineka explained that while they don't currently use a "buy and bill" model for expensive treatments due to financial risks, they do administer Prolia injections, with Jennie suggesting exploring a different reimbursement code (96401) for antineoplastic agents like Prolia. The conversation concluded with introductions to Florence, an internal medicine physician in Austin who is opening a new practice and joining the group.

Healthcare Billing Process Challenges

The group discussed challenges with healthcare billing and reimbursement processes, particularly around neurology and psychiatry services in Austin. Charu highlighted difficulties finding neurologists and psychiatrists who accept insurance, while the discussion also covered coding practices and billing procedures. The conversation focused on developing better reporting systems to track claims processing, with Florence and Vineka discussing the need for more detailed tracking of patient encounters and billing outcomes. Jennie advised starting with basic process verification, such as ensuring all patient encounters generate claims, before implementing more complex tracking systems.

Claims Processing Improvement Strategies

Jennie recommended Vineka focus on high-level claims reporting, asking yes/no questions about claim submission and rejection status, with deeper analysis only for rejected claims to identify patterns in issues like eligibility, timely filing, coding, or clearinghouse errors. Florence shared her experience learning to submit claims promptly rather than waiting for complete documentation, noting that insurance companies sometimes request additional documentation later. Jennie concluded by introducing an accountability measure, suggesting they establish specific action items for the following month to track progress on claims processing improvements.

EHR System Challenges Discussion

Vineka discussed her progress on coding tasks and enrolling in telehealth, aiming to streamline processes and eventually complete notes on the same day. The group discussed challenges with their current EHR system, Charm, including its limitations in integrating with AI scribes and handling questionnaires like the PHQ-9. Charu suggested exploring Practice Fusion as an alternative, while Florence and Jennie shared their experiences with more expensive EHR systems like Athena. The conversation concluded with Charu reflecting on the need to complete outstanding point-of-care testing tasks, highlighting the challenge of managing and organizing these tasks efficiently.

POCT Billing Process Improvements

Charu discussed challenges with billing and documentation for POCT A1C tests, noting she needs to implement better processes for coding and tracking these tests. She plans to create templates for POCT and ensure staff members input the correct codes when running tests. Charu also acknowledged being behind on notes due to spending too much time on detailed documentation, and expressed a goal to streamline her note-taking process while maintaining thoroughness. Florence mentioned working on the action checklist, particularly focusing on denial management and revenue cycle processes in Athena.

Athena System Implementation Challenges

The group discussed challenges with using Athena, particularly its complexity and the need for guidance to navigate its features effectively. Charu and Florence shared experiences about running reports and emphasized the importance of scheduled coaching sessions to learn how to use the system properly. Jennie suggested using templates and order sets in Athena to streamline processes, including for billing CPT codes related to depression and smoking cessation screenings.