When bank deposits and cash flow dwindle, the typical knee-jerk reaction is to blame the accounts receivable department: Have they been slacking off? After all, you see that outstanding receivables are continuing to age, and you have less money with which to buy equipment. It makes sense to look to the collections staff to revive the cash flow. Right? Not always. This tunnel vision can keep you from recognizing the real culprit — the intake process.

Rather than focusing on the back end of your operations, why not look toward your intake process for possible solutions to a cash shortage? Follow these four steps to find out how:

Step One: Order Intake

How well is your intake staff functioning? Are they obtaining complete intake forms? Are they gathering accurate information? These are questions that impact your bottom line daily. After all, why bother with documentation and billing if you can't even get a complete intake form? You may find that the patient didn't really qualify for the item he received. Control your fate: Get all the information up front that you need to make an educated decision about rendering or declining service.

Some companies' business philosophy is to accept every order regardless of the outcome or consequence. This philosophy typically is used to avoid alienating referral sources or to uphold a reputation for quality patient care. However, it also results in a less-than-profitable business or, at worst, a company that will not remain solvent. It's okay to be charitable in certain situations. However, to remain a profitable entity, you have to be reimbursed. And, in order to be reimbursed, you must take an accurate and complete dispensing order.

You can start by creating an intake form — with help from your intake staff — that works for your business model. For instance, an oxygen provider's intake form looks different than that of a rehab provider. If you already have a form that seems to work well for your company, review and revise it periodically to include Medicare and other regulatory changes. If, on the other hand, you have trouble with specific denials, attempt to retool your intake form to prevent these denials in the future.

During the brief but critical order intake process, referral sources usually want to do nothing more than get patients home and situated with their prescribed medical items — all with minimum effort. In their haste to release the patient, your staff may feel pressured to take an order from the referral source in a matter of seconds.

Yet, the information your staff gathers at the time of order will impact payment. If the intake staff doesn't gather important medical necessity information, reimbursement may not ensue. This is particularly true when dealing with Medicare patients whose orders include several items of durable medical equipment and supplies. For example, for a support surface such as an alternating pressure pad, you must obtain a written order prior to delivery. Failure to do so will result in a denial or potential recoupment by Medicare during a post-pay audit.

How do you walk the fine line between taking a quick order ensuring that an order will qualify the patient? It's all in the way the intake staff presents themselves. Train your intake staff to ask specific questions for particular items and payers. To help your staff work through challenging situations, try role-playing in training sessions, providing a script for staff to follow.

Step Two: Verifying Insurance

As important as the intake form is, the verification and authorization process also is an integral component of order intake. A complete insurance verification form should accompany the order for every new patient who is not a Medicare, Medicaid, private pay or commercial account.

A completed form indicates that you have checked with the patient's insurance company to determine benefits and eligibility. Although the insurance company does not guarantee payment, you still should attempt to gather coverage information. For instance, sometimes, learning that a case manager is involved tells you that you will be negotiating on price. You also might learn that you are not a contracted or in-network provider, which means that you will not be paid for services rendered. In this case, the patient can pay out-of-pocket or you can refer the patient to an in-network provider. Regardless, it is important to learn this information up front.

Step Three: Gathering Documentation

Once you have determined that you a have a valid order — based on a complete intake and verification process — you should gather medical necessity documents. The documentation-gathering step is essential to determining whether or not the patient truly qualifies for the products. This is the last step before billing, and is a procedure that will make or break payment.

Many companies already have delivered the equipment to the patient by this time and are merely awaiting the signed document from the physician before they can release billing. Others await the authorization from Medicaid before providing the item, while some await the signed and complete Medicare certificate of medical necessity before dispensing the product and preparing the billing.

The most important step in the documentation process is scrutinizing the accuracy and completeness of the medical necessity document after the doctor completes and signs the form. Without this step, you will receive denials for lack of medical need. A back-and-forth dynamic between the provider and the doctor usually is part of the documentation process. Hand delivery of the required documents to the doctor helps to minimize the number of times the document has to be sent back to the doctor. And educating the doctor's staff often helps: Provide the doctor's staff with tools to determine what qualifies a patient for a particular item.

Finally, closely monitor and track your outstanding, unsigned medical necessity documents. Sort reports by doctor, doctor group or clinic. Then, further sort the documents by dollars and days outstanding for specific items (e.g., rental versus sale items; oxygen versus a folding walker). This process will help you focus on the difficult doctors who represent the bulk of your outstanding unsigned and incomplete paperwork.

Step Four: Order Confirmation

The final step before releasing billing is the quality control or order-confirmation process, which occurs after the item is delivered and the doctor's office returns the signed, completed documentation. Someone who understands inventory control, basic billing requirements and the overall operational flow — and who is detail-oriented and has an eye for finding errors — should handle this function. A multitude of errors could arise at this stage, from an incorrect code to a data-entry problem. The variables are numerous and finding these errors requires intense concentration.

After approving the file for complete and accurate paperwork and the computer for proper entry, you may release the claim to billing. From here, the billing department prints a pre-billing edit report to conduct a final review of the bill before submitting the bill to the insurance company. This step affords you one last opportunity to reverse errors.

If managed appropriately and given the proper attention, the intake department will impact your outstanding A/R positively and will improve your company's overall profitability.

Miriam Lieber is president of Lieber Consulting, specializing in operations management and reimbursement for the home medical equipment industry. She can be reached via email at mllieber@pacbell.net or via phone at 818/789-0670.