Checklist of vital questions to ask if your medical billing is done in-house.
Years ago, in-house billing had multiple advantages. The claim preparation and claim adjudication process was simple, denied claims were unusual, payors paid most of the patients’ claims and pre-authorizations were rare.
Today, the complexity of technological advancements, perennial regulatory changes, expansion of diagnostic codes (ICD-9 to ICD-10), escalation of privacy (HIPAA) risks, and many other factors, have transformed the “billing process” from an informal set of tasks, to a profession unto itself.
Here are the top 10 questions to consider as you evaluate the value and efficacy of your in-house process and wrestle with the issues that making a change may require.
- Am I confident that every exam I interpret is in the billing system?
- What documentation confirms this?
- Are all the procedures I perform coded accurately by certified coders?
- Are all of our claims filed consistently and timely?
- Claims should be consistently filed within 5-7 days from date of service.
- Are the money management functions within the billing process protected from irregularity by appropriate segregation of duties?
- Are our Medicare claims adversely impacted by not qualifying for PQRS or other quality initiative incentives?
- Is there a daily reconciliation of all transactions between the billing process and our bank account(s)?
- What confirmation do I have to perpetually confirm that payors are complying with our commercial payor contracts?
- Are we receiving patient complaints?
- What is our percentage of denied claims?
- Average should be at or below the 3% to 5% for claims denied not due to incorrect payor eligibility.
- Do we have a Living Compliance Plan?
If you have positive confirmation from the answers to these top 10 questions, that’s great! If you still have concerns, here are a few bonus thoughts to be certain you are in great shape…
- If one or two of our key people left us, would a transition to new personnel be easy and seamless?
- Are our commercial payor contracts fair and reasonable?
- Is our Provider Enrollment process and revalidation process sound?
- Does our staff have the bandwidth to stay current with the legislative and regulatory changes?
- Do we (or our practice manager) receive value added reports to help us confirm our performance, anticipate trend changes, and manage our practice?
A physician group leader shared the following:
“Despite the hassles, we thought our in-house billing department was doing a good job. We felt a tremendous responsibility to the people we employed, so we dragged our feet. Our physician practice continued to lose money while we delayed. When we outsourced out billing to HealthPro, we recovered revenue of over 20% annually. We would have outsourced YEARS earlier if knew then what we know now.”
– Gerald Smidebush, MD
In the words of Ronald Reagan, “Trust, but verify.” Confirm that your in-house process is solid and secure. If it’s not, and you do choose to outsource your medical billing, be certain that the entity you choose is invested in your success and that they can demonstrate their competency through their processes and performance and confirm their integrity by speaking with their current clients.
While our primary purpose and mission is revenue cycle management, our leaders have decades of physician practice management experience. Call for a free consultation, for up to 1 hour with either John Stiles, Brendala Anspaugh or Don Rodden. We will gladly sign any reasonable confidentiality agreement and dialogue with you further about how you can lead your group in a transformative direction.