Electronic Medical Billing Software For Rehab Clinics and Chiropractic Offices - Naive Taxonomy

Gerber's E-Myth theory applies well to billing: mostcategories: encoders, revenue-cycle management
billing services fail because the founders aretools, and artificial intelligence systems:
"technicians" who are inspired to start a business
without knowledge of how successful businesses1. Encoders help coding personnel improve
run. Typically billing "technicians," who are skilled atconsistency. An encoder is a database-driven
billing and may enjoy coding, start their own billingsoftware, which prints a list of codes in return to
operation and continue doing the work they area procedure name or problem description. Typical
skilled at. However without access to solidencoders include ICD-9, CPT, and HCPCS books.
technology and industrial-grade processes, theseAdditionally, encoders provide access to
"technicians" soon find themselves unable to scaletransmittals and bulletins from Medicare, advice
up. Rather than working "on" the business, theyfrom the AMA's CPT Assistant, CCI, and details
work "in" the business, merely owning a jobfrom national coverage decisions (NCDs). The
instead of a business.database must be continuously updated, which
Billing is especially hard because of codingcan be accomplished with ongoing Internet
complexity and payer adversity. The shearresearch.
number of codes and rules create an2. Revenue-Cycle Management tools scrub claims
environment, where a coder is unable to performand manage the claim payment cycle. Scrubbing
consistently. It includes more than 8,500starts with missing field identification and testing
procedure codes and modifiers, over 16,000of medical necessity rules, typically including CCI,
diagnosis codes, and millions of rules for medicalLMRP, and, most importantly, local payer rules.
necessity, correct coding initiative (CCI), localThe knowledge base, consisting of rules like "For
medical review policy (LMRP) and bundling. Evenpayer X and CPT code Y, do Z," must be
highly trained coders have difficulty maintainingcontinuously updated. However, in contrast to
coding consistency. Their CPT choices areencoders, up-to-date maintenance of the
inconsistent fifteen percent of the time, while theirknowledge base cannot be accomplished by
ICD-9 codes disagree with their own earlierresearch alone. Since some payers do not publish
choices almost half the time (Perspectives intheir payment policies, the rule base must be built
Health Information Management, Fall 2006).through a live trial-and-error process. In this
Billing complexity also generates opportunities forprocess, a delay or a denial triggers a dialog with
providers to commit fraud and for payers tothe payer, the discovery of a missing rule, and
benefit at the provider's expense. An in-housesoftware changes to encode the new rule. This
billing operation and a naive outsourced billing officeprocedure is much more time consuming and
owner are both helpless against insuranceexpensive for both the vendor and the provider
companies armed with a powerful three-prongedthat happens to experience the inconsistency.
system to keep providers' money: solid business3. Artificial Intelligence systems typically use
strategy, well-documented and professionallynatural language processing algorithms to make
managed processes, and leading-edge technology.thuman-computer interaction more intuitive and
A scalable billing service requires disciplinedeasy. Such tools accept an electronic medical
performance measurement, process consistency,record of the encounter and return a coded
and industrial-grade technology. Provider-side billingsuperbill, which include diagnosis and procedures
technology can be roughly divided into threecodes.