| Over four thousand vendors of medical | | | | or New Jersey vendors without formal |
| billing services offer solutions to | | | | certification from New Jersey Department |
| medical practices nationwide in response | | | | of Banking and Insurance. 5. References |
| to poor in-house billing performance and | | | | Ask for a list of references owning |
| increasing regulatory scrutiny of | | | | similar practices. Are the clients |
| billing processes. On one hand, such a | | | | satisfied with results, support, and |
| large number of outsourced billing | | | | changes over time? Can they quantify |
| solutions ensure continued | | | | billing service quality in terms of |
| competitiveness in terms of both service | | | | Accounts Receivable over 120 days and |
| quality and pricing. On the other hand, | | | | underpayment reduction? 6. Billing |
| the lack of uniform service standards | | | | Service Quality Make a list of metrics |
| and metrics among the vendors, combined | | | | used by the service. Focus on |
| with their large numbers, makes the | | | | collections completeness and payment |
| process of vendor selection difficult | | | | delay. Can the vendor quantify the |
| and error-prone. While the availability | | | | differences between payers and between |
| of a large vendor selection allows | | | | various CPT codes in real time? Does |
| finding an alternative to unsatisfactory | | | | the vendor follow up every denial? What |
| service, billing vendor-switching costs | | | | is the denial followup success rate? 7. |
| remain high, motivating extra effort and | | | | Compliance Consider two aspects of |
| focus during the stage of vendor | | | | compliance, namely, your practice and |
| selection. This article outlines basic | | | | billing service. Request to review a |
| thirteen-step guidelines for an | | | | written compliance program for the |
| effective and efficient medical billing | | | | billing service. Ask for its update |
| vendor selection process. 1. Scope of | | | | procedure. For your practice, request |
| Services Decide if you are looking for | | | | an interface to a legal service |
| billing technology, billing service, or | | | | specializing in post-payment audit risk |
| practice workflow solution. If you plan | | | | management. 8. Communications Protocols |
| to manage billing in-house, you may only | | | | A disciplined vendor has a formal and |
| need a billing technology solution. In | | | | simple process to report problems and |
| that case your next decision is whether | | | | track their resolution. Your practice |
| you wish to own the technology or to | | | | must have a competent account manager |
| rent access to it.Complete practice | | | | and regular meetings scheduled to review |
| workflow solution belongs to the other | | | | outstanding problems. 9. Data Security |
| end of the spectrum of services and | | | | and Protection Review data center |
| starts with appointment scheduling and | | | | facilities. Ask for evidence on HIPAA |
| includes electronic medical records, | | | | compliance: claims must be viewed only |
| SOAP notes, and billing. Few vendors | | | | on the "need to know" basis, access to |
| today offer such integrated packages as | | | | claims and modifications must be |
| they require powerful vericle-like | | | | thoroughly documented. Data must be |
| technologies used by trained and skilled | | | | protected with redundant disaster |
| personnel implementing rigorous and | | | | recovery measures. Review backup |
| disciplined service processes.A | | | | process, backup intervals, and data |
| billing-only service belongs to the | | | | restore capabilities. 10. Data Entry |
| middle ground between the choices | | | | Protocols Modern technologies allow the |
| described above and may include coding, | | | | doctor to take over coding and reduce |
| electronic claim submission, "scrubbing" | | | | the billing role down to claims |
| (validation), payment posting, claim and | | | | processing and followup. |
| payment reconciliation, followup, | | | | Technology-competent vendor will supply |
| secondary submission, and patient | | | | your superbill online, along with a |
| billing. 2. Billing Model Billing model | | | | separate form for patient and charge |
| selection is the second most important | | | | entry, EOB posting, and on-line claim |
| decision in your definition of desired | | | | editing. Similarly, much of data entry |
| vendor. What is the policy of followup | | | | validity, including some of claim |
| process prioritization? Who decides on | | | | scrubbing will be done online at the |
| which claims to followup? Which of the | | | | point of data entry. 11. Processes for |
| following functions are automated: | | | | Continuous Improvement A successful |
| upfront claim validation, submission, | | | | vendor must have developed an effective |
| reconciliation, and follow-up workload | | | | process to identify and resolve systemic |
| allocation? 3. Reporting and | | | | errors. Without such a process, the |
| Transparency Transparency is a critical | | | | vendor will lose competitiveness and you |
| aspect of outsourcing billing service | | | | will have to switch the services at a |
| because without transparency the service | | | | later stage. 12. Size and Scalability |
| may not be reliable. To be able to | | | | Automation defines scalability. The |
| observe every step of the billing | | | | more steps are automated, the easier it |
| process on a continuous 24 x 7 basis, | | | | is for the vendor to take on new clients |
| reporting must be available using a | | | | without impairing service quality. To |
| secure HIPAA compliant connection over | | | | understand vendor's scalability, you |
| the Internet.The ability to provide | | | | must compare gross annual billings, |
| timely and useful reports depends on | | | | claim volumes, and numbers of doctors. |
| billing model (see above) and billing | | | | Avoid vendors that would have to treble |
| technology. Vendors that manage their | | | | their scale because of serving your |
| own billing technology typically have | | | | practice. 13. Staffing Review staff |
| better control of reporting capabilities | | | | numbers, educational background, |
| in terms of scope, analysis, frequency, | | | | experience, and reporting structure. |
| and transparency. At the minimum, the | | | | Understand the process of quality |
| following features must be available: | | | | assurance and accountability. Avoid |
| Operational Report shows total claims | | | | vendors that would have to double their |
| and $ amounts submitted, paid, adjusted, | | | | staff to serve your account. 14. |
| written off, and failed. It allows | | | | Pricing Most billing service vendors |
| breakdown by cpt, payer, referral, or a | | | | charge a percentage of monthly |
| combination of such dimensions. | | | | collections. This percentage varies |
| Denials Report shows the list of denied | | | | across specialties, depending on the |
| claims and a log of followup actions. By | | | | average claim billing size and claim |
| sorting it by amount paid, you can tell | | | | volume. Note that the lowest cost |
| the smallest payment the billing service | | | | provider is not necessarily the best. |
| will fight for. Compliance Report | | | | Read our companion article on relative |
| shows the potential for post-payment | | | | value of billing quality and |
| audit and itemizes compliance | | | | price-performance relationship.Yuval |
| violations. Reporting Frequency | | | | Lirov, PhD, author of "Mission Critical |
| defines the data update intervals on | | | | Systems Management" (Prentice Hall, |
| existing reports and turnaround time for | | | | 1997), inventor of multiple patents in |
| new reports. Data Aggregation and | | | | artificial intelligence and computer |
| Analysis must allow arbitrary data | | | | security, and CEO of Billing |
| aggregation and drill-in. Export to | | | | Technologies. Vericle delivers |
| Excel spreadsheets for further analysis | | | | comprehensive practice workflow engine |
| is a very useful feature. 4. | | | | that integrates patient scheduling, |
| Certification Request formal | | | | electronic medical records (EMR), |
| certification of compliance with basic | | | | billing, transcription, and compliance |
| regulatory requirements. Stay away from | | | | management. It improves billing |
| national vendors with New Jersey clients | | | | performance and reduces audit risk. |