For many physicians and other providers, the decision to use the services of a medical billing company often hangs on cost as well as specialty. While these are perfectly valid concerns, there is much more to the whole picture. You’ll want to know what you can expect if a claim is denied or rejected. What reports will be generated for tracking and how easily will you be able to access your account? This blog covers five of the most important elements of outsourced medical billing and why you need answers before you sign a contract.

How long has your company been doing medical claims processing? 

Because the field of medical billing is becoming ever more complex, especially with the adoption of ICD-10 codes and other major changes, you need a company whose billers possess common sense and experience, especially within your specialty. While certification is a very good thing to have, it cannot, in most experts’ views, replace the experience gained from handling many different types of claims over time.

You also need to know whether a dedicated contact person will be assigned to you in the event of questions or other issues that may arise. If the company plans to assign a regular biller to work on your daily claims and other receivables, knowing this up front can be helpful if you have questions on a specific claim, as well as what happens if your biller goes on vacation or is out sick to allow service levels to remain consistent.  

How does the company keep its personnel updated in the latest regulatory changes? Ask also how they monitor themselves and measure the quality of billing performed. What benchmarks are used to evaluate performance and what do they consider a good, fair, poor or indifferent performance on a client’s behalf? 

Will your system be compatible with the one I currently use or will I need to a new one?

If conversion is necessary, what will it cost and how will your company help in the transition process?  Remember that you likely already have expensive practice management systems in place, and while you should be flexible and open to some change, you shouldn’t have to completely redo everything to accommodate your billing company.

How secure is the company’s system and what safeguards do they take to protect data? How HIPAA-compliant is the service? There needs to be a designated HIPAA security person with periodic assessments with records of compliance progress.

Ask about data, email, fax security and business associate agreements also.

What services am I getting for my billing costs?

You also want to know the cost, of course, and what you’ll get for your billing dollars. While it might be tempting to save a bit, as with anything else, you get what you pay for. Some services normally expected but are often excluded from lower-priced companies can include

• Follow-up on low-ticket claims
• Sending patient statements
• Working accounts receivable – how many are over 90 days?
• Managing resubmitting denied claims
• Alerting provider clients about any contract issues that may arise

What reports can I expect to receive?

You’ll want to know what the billing company routinely sends out as well as whether you will be able to run reports and access your account in “real time.” You will probably want to be able to access claims and run reports within your own system also. Ask the company for a set of sample reports to give you a good idea of what data will be provided and whether they will reveal information about their performance as well as your business. As a rule, as a minimum, you should receive reporting on the following:

• Aged account receivables
• Credit balances
• Denial reports

How will your company handle denied, rejected or unpaid claims?

While some mistakenly use these terms interchangeably, they are not the same:

• A rejection means that a claim doesn’t meet a payer’s data requirements, and could be something as simple as a transposed digit on a patient’s insurance account number and cannot be entered into their systems for processing.  Once the errors are corrected, a claim may be resubmitted for consideration.
• Denied claims have been submitted and processed, but were turned down for payment. These claims cannot be simply resubmitted without knowing why the denial was made and an appeal or reconsideration requested. Missing information, duplicate billing, or non-covered services are a few reasons for denials.
• An unpaid claim is usually eligible for payment but may have been overlooked and never submitted, or needs to be resubmitted, if within the time-frame. Careless billing practices are the biggest reasons for unpaid claims.

All practices need a policy in place to deal with denied claims, as this is a huge revenue drain for most practices. Ideally, the denial rate should be five percent or less, but all denials need to tracked and analyzed through denial reports to determine if the problems lie with a certain payer, whether certain services are targeted or other criteria.

A good billing service should be able to minimize the chances of this happening by taking steps to identify and remove the causes through a predictive analysis and routine audits of chart documentation quality to catch problems before submitting.

When you decide to outsource your medical billing services

Partnering with a medical billing service is not a decision to make quickly or lightly. Be sure to take your time investigating, including online feedback as well as old-fashioned word-of-mouth. As one of the leading medical claims billing and practice management services, M-Scribe has been helping practices of all specialties and sizes with their billing, audit evaluation and other revenue management concerns since 2002. Contact me at 770-666-0470 or email for a free analysis of your practice and learn how we can help boost revenue while ensuring that your practice is fully compliant with all applicable regulations.

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