59% of billing service providers do not review EOBs and 55% of billing service providers have never appealed a denied claim, according to MAB survey.

Billing Services

Scope of services may include complete practice workflow starting with appointment scheduling to electronic medical records, SOAP notes, and billing, or it may only be focused on billing. Billing too may include electronic submission, validation, payment posting, reconciliation, followup, secondary submission, and patient billing. Each aspect mentioned above should be ranked according to specificity and coverage.

Billing Model

Is it an aggressive or a defensive billing firm? Which of the following functions are automated: upfront validation, submission, reconciliation, and follow-up workload allocation? Which specific errors are handled automatically at the upfront validation level?

Reporting

1. Operational Report shows total claims and $ amounts submitted, paid, adjusted, written off, and failed. It allows breakdown by cpt, payer, referral, or a combination of such dimensions. Examples:
1. Billed, paid, balance, AR (30, 60, 120 days) 2005 and for each month by facility, doctor, CPT code, and payer.
2. Which CPT code was the best (worst) in terms of revenue (% paid) in 2005?
3. Which office and which doctor was the most productive in 2005 ($ paid/visit) by CPT code and in total?
4. Which payer underpaid the most in 2005 across all offices and individually within each office?
5. Which payer underpaid the most on the best revenue-generating CPT code?
6. Which referring physician referred most business in 2005 across all offices and individually within each office?
7. What was the distribution of CPT codes for the best reffering physician?
8. Which office had most no-shows in 2005 across all offices and individually within each office?
9. Which doctor had most violations of coding audit guidelines in 2005? Who is the worst offender right now?
10. Off the total number of patient visits in January 2006, how many were paid, are still held by payers, waiting for doctor's response, not charged? Same question for July 2005.
2. Denials Report shows a list of denied claims and a log of followup actions. By sorting it by amount paid, you can tell the smallest payment the billing service will fight for.
1. How many claims were underpaid in 2005?
2. Which claims were underpaid during 2005 according to contract and what was done to recover the differences?
3. Reporting Frequency: What is the turnaround time for new reports? How frequently can you receive the reports? What is the method to access them?
4. Data Aggregation and Analysis: If web-based access is available, do the reports allow drill-into more detail? Is it possible to refine and sort reports on-line and along multiple criteria? Is it possible to export to Excel spreadsheets for further analysis?

References

What do current clients think about the quality of service? Can a client comment about any of the criteria on this list as well as cite specific improvements over time?

Billing Service Quality

What aspects of the billing process are measured? Do they include separate collections and payment delay measures? How is delay measure defined: does it measure the time elapsed from claim creation until payment by the primary payer or does it start at service delivery and measure the entire period until receiving payments from both payers and the patient? Is a histogram of payments available for client review on a periodic basis?

Billing Process Quality

Which processing quality metrics collected? Do they include coding, submission, and follow up delay metrics? Do the metrics include both claim stats as well as fiscal value statistics?

Billing Transparency

Can the candidate billing firm readily provide quality metrics and access to every step of the billing process on a continuous 24 x 7 basis over the Internet? Transparency is a critical aspect of outsourcing billing service because without transparency the service may not be reliable.

Compliance

Does the billing company have a compliance program in place? Is there a Code of Conduct?

Communications

Is there a formal and simple process to report problems and track their resolution? Is there a competent account manager? How often a meeting is held to review outstanding problems?

Technology

Does the firm offer access to specialized technology? Does it require software installation and maintenance or is it available on the Internet using a standard browser?

Data Security and Protection

What are data center facilities? Is the technology HIPAA compliant? Is the access to the claims secure? Is data protected? What are disaster recovery facilities? Is there a regular backup process? At what intervals? Where is the backup data stored?

Data Entry

Is Superbill available online? Can the claims be just faxed? Is there a separate form for patient and charge entry, EOB posting, and on-line claim editing? Are any of the claim validity tests available during data entry?

Continuous Improvement

How does the firm identify systemic errors? How does it ensure that previously made mistakes do not repeat?

Scalability

What billing process steps are automated? Can the firm take on another client without impairing service quality?

Size

What are the firm’s gross annual billings? How many claims does it process annually? How many practices is the firm billing for? What specialties does it currently handle?

Staff

How large is the staff and what is the reporting structure? What is the educational background and experience of staff and management? Would adding your practice require the billing firm to hire additional staff?

Responsiveness

Consider technical systems access and problems beyond late AR or incomplete payment. How quickly does it take to respond to a technical problem notification? How quickly does it take to resolve a problem?

Pricing

Most billing firms charge for services a percentage of monthly collections. This percentage varies among specialties, depending on the average claim billing size and claim volume. Average price for billing service varies between 5% and 13%, according to MAB survey. Note that the lowest cost provider is not necessarily the best. Focus on quality. Remember that 10% improvement in quality means 10 times more to your bottom line than 1% reduction in price. It is in the physician’s interest to see that a quality billing service makes an adequate profit. Otherwise, the billing firm will be forced to reduce the amount of effort spent on supporting the practice, resulting in lower quality.

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