RCM Tip #7: Understand Your Insurance Carriers


How integrated practice management software and billing services can help improve ENT billing processes in your practice

Insurance payments are the lifeblood of your practice, so it’s imperative to have a strong understanding of who’s writing the checks. Why? You want the ability to adapt your otolaryngology billing processes to ensure timely and complete payment on all your claims.

Each month, I will provide a tip to help you better manage your practice’s revenue cycle and to help improve your bottom line. This month’s tip will focus on some key areas to help maximize reimbursement from insurance carriers, or payers. Understanding and working in alignment with your insurance carriers are significant steps towards healthy medical billing processes and your overall practice success.

Perform Insurance Eligibility Verification  

As with most things in life, it’s best to identify and avoid issues before they happen. The same can be said about your billing and ENT coding processes. By performing insurance eligibility verification on all patients before their scheduled appointments, you can identify potential issues with an insurance carrier before any billable services have been rendered.

Verifying a patient’s active health insurance coverage helps you gather information like:

  • Payable benefits
  • Copays/coinsurance
  • Deductibles
  • Policy coverage details
  • Referral requirements and more

Advanced practice management systems often provide functionality to check a patient’s insurance eligibility in near real-time, helping to avoid claim denials or rejections later in the revenue cycle. This can save valuable time and effort with your billing staff and speed up your time to collection. Verifying insurance eligibility can also help improve the patient experience, by providing clear copay, coinsurance and deductible information helping to answer a patient’s questions about their financial responsibilities prior to a visit.

Adhere to Timely Filing Deadlines

Most health insurance carriers have time limits on how long after the date of service a claim can be submitted. These time limits can vary widely for each carrier, with some being as short as 30 days and others as long as 2 years. At first glance, these timely filing deadlines may seem doable, but denials due to failing to file claim in a timely fashion are fairly common. It can be very difficult to successfully appeal a claim denied for timely filing, which means you could miss out on hard earned money. You should know the timely filing deadlines for your top payers and keep an eye on open claims by payer to make sure they are filed by the set deadlines.

It’s important to note that the timely filing deadline is almost always based off of the date of service, not the date that the claim was created or submitted. This means that every day you put off completing documentation is another day gone for the filing deadline.

Additionally, obtaining the patient’s accurate and complete insurance information before the visit can eliminate the need for billing staff to follow up with patients or payers. Doing so can help you avoid additional delays in the medical claims submission process.

Keep Fee Schedules Up-To-Date

Each payer has its own fee schedule, listing the maximum reimbursement amount for covered medical services or procedures. You can find these fee schedules by visiting the payer’s website or making a phone call to the payer. Payers update fee schedules annually for current and new CPT codes, and you should do the same for your ENT practice. You want to ensure you are charging payers appropriately and maximizing your reimbursement.

Setting your fee schedule above the highest amount paid by your top insurance carrier helps you collect the maximum reimbursement for the procedure or service provided. If you were to charge less than the allowed amount, the payer would only reimburse the amount charged, and not the maximum allowed. This means you could leave your hard-earned money on the table.

Various strategies exist for evaluating and setting your practice’s fee schedule—from charging a percentage of Medicare’s fee schedule or assessing the true time and costs associated with offering each procedure or service. Keep in mind that patients are shouldering a larger portion of their healthcare costs, so setting your fee schedule too high could cause sticker shock for your patients and prompt them to consider other providers. Read more about how to review and adjust your practice’s fee schedules in last month’s blog post.

Manage Denials and Rejections 

Sometimes the terms “rejection” and “denial” are used interchangeably, but there are major differences between the two terms and how each should be managed.

Claims are rejected when they are missing or have invalid information required for processing. Incorrect insurance ID numbers or missing ICD-10 codes are two examples. Rejections usually happen during the clearinghouse scrub step, but they may also occur when submitted to the payer. Rejected medical claims were never entered into the payer’s system, so they usually can be corrected and resubmitted to the payer.

Denied claims are medical claims that were received and processed by the payer, but deemed not payable due to violations of the insurance policy terms or other vital errors. Denied claims usually come back with an Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) and an explanation of the denial. Denied claims must be resubmitted with an appeal or reconsideration request.

Claim rejections and denials can be costly and time-consuming to manage, so it’s important to make sure you are submitting clean claims the first time around. If your denial or rejection rates are excessive, investigate why and analyze the common causes. When working to resolve unpaid medical claims, look for patterns relative to each insurance carrier. If you’re able to discover a common factor, you can modify your medical ENT billing procedures and style to help avoid future rejections and denials.

Stay on Top of Your A/R

Accounts receivable, also known as A/R, is the outstanding money owed to your ENT practice by patients, payers or other parties for any services rendered and billed. High A/R means you may not be getting paid for all of the work and services you have performed. You should also monitor the aging of your A/R, and understand the general time frame of your outstanding balances that are within 30 days, 45 days, 60 days, 90 days, or 120+ days. The longer a claim goes unpaid, the more difficult it is to collect the payment due. 

The process of managing your A/R involves:

  • Identifying unpaid claims
  • Understanding why payment has been delayed
  • Assessing necessary actions to improve collections

It’s also important to identify trends in reimbursement by payer in order to identify which claims need to be prioritized. You should know which payers take longer to pay claims, and if there are any actions that can be taken to avoid delays in payment. By trending your A/R over time and referencing industry benchmarks, you may be able to identify best ENT billing practices that can speed up your collections.

Enlist the Help of a Comprehensive ENT Billing Service 

All of these billing practices can seem overwhelming to implement, especially for smaller ENT practices. Some practices have billing staff assigned to managing A/R alone. If you don’t have the time or resources to fully manage your revenue cycle, it may be time to consider a comprehensive billing service to help.

modmed® BOOST is an all-in-one solution that combines our practice management software and our business operations services to address your ENT practice’s revenue cycle needs.

Dedicated ENT billing specialists focus on your claims management process from performing insurance eligibility checks, to custom claims scrubbing, to managing denials and rejections and working your A/R. The modmed BOOST team works within your Modernizing Medicine practice management system, so you maintain visibility and control over your practice’s financials. In addition to managing daily revenue cycle management tasks, client managers can provide advanced analysis of your practice’s financial performance to help identify opportunities to improve ENT billing processes and potentially collect more of what you are owed.

Here’s What a Client Shared About modmed BOOST:

“I trust that Modernizing Medicine looks out for the financial health of my practice. I have seen a decrease in my denial rate and an increase in my revenue coming in. I have confidence that I am collecting what I deserve.”

—Jessica Kappelman, MD, MPH

Interested in learning how modmed BOOST can help improve your bottom line?

Patrick DeAngelo

Patrick DeAngelo


Patrick DeAngelo is the Senior Vice President and General Manager of Business Services. He is responsible for revenue cycle operations and sales, as well as Modernizing Medicine professional services, including MIPS Advising.

Over the past 20 years, Patrick’s leadership experience in all aspects of revenue cycle, patient experience and practice workflow have driven both top and bottom line improvement to physicians, hospitals and health systems. Patrick’s focus on setting goals based on quality and results-driven metrics inspires teams to strive for continuous improvement while promoting a high-performing, enthusiastic corporate culture. 


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