Outsourced Medical Billing Software and Service Selection in 14 Steps

Over four thousand vendors of medical billinguseful feature.
services offer solutions to medical practices4. Certification
nationwide in response to poor in-house billingRequest formal certification of compliance with
performance and increasing regulatory scrutiny ofbasic regulatory requirements. Stay away from
billing processes. On one hand, such a largenational vendors with New Jersey clients or New
number of outsourced billing solutions ensureJersey vendors without formal certification from
continued competitiveness in terms of bothNew Jersey Department of Banking and
service quality and pricing. On the other hand, theInsurance.
lack of uniform service standards and metrics5. References
among the vendors, combined with their largeAsk for a list of references owning similar
numbers, makes the process of vendor selectionpractices. Are the clients satisfied with results,
difficult and error-prone. While the availability of asupport, and changes over time? Can they
large vendor selection allows finding an alternativequantify billing service quality in terms of Accounts
to unsatisfactory service, billing vendor-switchingReceivable over 120 days and underpayment
costs remain high, motivating extra effort andreduction?
focus during the stage of vendor selection. This6. Billing Service Quality
article outlines basic fourteen-step guidelines for anMake a list of metrics used by the service. Focus
effective and efficient medical billing vendoron collections completeness and payment delay.
selection process.Can the vendor quantify the differences between
1. Scope of Servicespayers and between various CPT codes in real
Decide if you are looking for billing technology,time? Does the vendor follow up every denial?
billing service, or practice workflow solution. If youWhat is the denial followup success rate?
plan to manage billing in-house, you may only need7. Compliance
a billing technology solution. In that case your nextConsider two aspects of compliance, namely, your
decision is whether you wish to own thepractice and billing service. Request to review a
technology or to rent access to it.written compliance program for the billing service.
Complete practice workflow solution belongs toAsk for its update procedure. For your practice,
the other end of the spectrum of services andrequest an interface to a legal service specializing
starts with appointment scheduling and includesin post-payment audit risk management.
electronic medical records, SOAP notes, and billing.8. Communications Protocols
Few vendors today offer such integratedA disciplined vendor has a formal and simple
packages as they require powerful vericle-likeprocess to report problems and track their
technologies used by trained and skilled personnelresolution. Your practice must have a competent
implementing rigorous and disciplined serviceaccount manager and regular meetings scheduled
processes.to review outstanding problems.
A billing-only service belongs to the middle ground9. Data Security and Protection
between the choices described above and mayReview data center facilities. Ask for evidence on
include coding, electronic claim submission,HIPAA compliance: claims must be viewed only on
"scrubbing" (validation), payment posting, claim andthe "need to know" basis, access to claims and
payment reconciliation, followup, secondarymodifications must be thoroughly documented.
submission, and patient billing.Data must be protected with redundant disaster
2. Billing Modelrecovery measures. Review backup process,
Billing model selection is the second mostbackup intervals, and data restore capabilities.
important decision in your definition of desired10. Data Entry Protocols
vendor. What is the policy of followup processModern technologies allow the doctor to take
prioritization? Who decides on which claims toover coding and reduce the billing role down to
followup? Which of the following functions areclaims processing and followup.
automated: upfront claim validation, submission,Technology-competent vendor will supply your
reconciliation, and follow-up workload allocation?superbill online, along with a separate form for
3. Reporting and Transparencypatient and charge entry, EOB posting, and on-line
Transparency is a critical aspect of outsourcingclaim editing. Similarly, much of data entry validity,
billing service because without transparency theincluding some of claim scrubbing will be done
service may not be reliable. To be able toonline at the point of data entry.
observe every step of the billing process on a11. Processes for Continuous Improvement
continuous 24 x 7 basis, reporting must beA successful vendor must have developed an
available using a secure HIPAA complianteffective process to identify and resolve
connection over the Internet.systemic errors. Without such a process, the
The ability to provide timely and useful reportsvendor will lose competitiveness and you will have
depends on billing model (see above) and billingto switch the services at a later stage.
technology. Vendors that manage their own billing12. Size and Scalability
technology typically have better control ofAutomation defines scalability. The more steps are
reporting capabilities in terms of scope, analysis,automated, the easier it is for the vendor to take
frequency, and transparency. At the minimum,on new clients without impairing service quality. To
the following features must be available:understand vendor's scalability, you must compare
- Operational Report shows total claims and $gross annual billings, claim volumes, and numbers
amounts submitted, paid, adjusted, written off,of doctors. Avoid vendors that would have to
and failed. It allows breakdown by cpt, payer,treble their scale because of serving your practice.
referral, or a combination of such dimensions.13. Staffing
- Denials Report shows the list of denied claimsReview staff numbers, educational background,
and a log of followup actions. By sorting it byexperience, and reporting structure. Understand
amount paid, you can tell the smallest paymentthe process of quality assurance and
the billing service will fight for.accountability. Avoid vendors that would have to
- Compliance Report shows the potential fordouble their staff to serve your account.
post-payment audit and itemizes compliance14. Pricing
violations.Most billing service vendors charge a percentage
- Reporting Frequency defines the data updateof monthly collections. This percentage varies
intervals on existing reports and turnaround timeacross specialties, depending on the average claim
for new reports.billing size and claim volume. Note that the lowest
- Data Aggregation and Analysis must allowcost provider is not necessarily the best. Read our
arbitrary data aggregation and drill-in. Export tocompanion article on relative value of billing quality
Excel spreadsheets for further analysis is a veryand price-performance relationship.