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Top 3 Risks Physician Groups Take in Their Medical Billing Process


Why do people take excessive risks?

Taking Risks
  1. They love the thrill of risk
  2. There is a corresponding reward to taking the risk
  3. They don’t see the risk
  4. They don’t believe they have any other good option

There may be others as well, but many of the underlying reasons fall into one of these categories.

So… why do physicians and physician groups take unnecessary risks when it comes to their largest expenditure (other than their compensation), which is usually their billing process.

1. Loving the Thrill of Risk

To date, I’ve never met a physician group that loved the thrill of taking risks, so we’ll check that one off the list.

2. There’s a Greater Reward in Taking the Risk

This one could perhaps have some merit. For instance, if a billing company can actually provide a superior service for a bargain basement price, that’s a great deal. But some questions probably need to be asked to validate the claim. For instance:

  • How can you deploy capital and stay invested in top end technology if you are suppressing costs extraordinarily?
  • How can you keep continuity of good talent (people) if you keep wages as low as possible to maximize (the billing company’s) net earnings?
  • How can you adequately pay attention to metrics and details, validate and audit throughput, if you don’t allocate resources to these “non-productive” activities?

3. Where’s the Risk?

Well, let’s touch on the two most significant risks.  Loss of money and its cousin, being penalized or fined for non-compliance.

Loss of Money

I think the more practical risk for most physicians, is simply losing money. Because billing is so complex and there are so many variables, it makes it difficult to define where money is being lost.

Unless your systems, processes and oversight are diligent and process driven, it’s very easy to lose 5% or 10% or your revenue on an ongoing basis and not be able to easily identify it.

You may only be losing 1.7% due to your billing company not working denied claims correctly, maybe 0.6% due to timely filing issues, 3.4% due to procedures that never get billed due to disruptions in the matrix of electronic transfers of data from your facilities to the billing process, 2.1% in inadequate notification and communication to patients follow-up, 1.1% due to delays or failure to turn slow accounts over to a collection agency in a timely manner, and oh yeah, 2.8% due to lesser CPT and/or incorrect ICD-10 codes being applied to claims.

So, with just a little slippage here and there, you are now down 8.9%, but none of it is easy to identify and slick talk can keep you convinced you’re getting all you should be getting.

Violation of Regulations and Agreements

The second major risk is finding yourself in violation of government regulations (CMS, Medicaid, Workers Compensation, etc.) or your commercial payor contracts. These can be like land mines, because all payors have a right to retroactively go back in time to audit your transactions and “recoup” money they’ve paid based on their findings. Now, they’ve taken your money, while questioning your credibility, requiring you to invest time and resources to fight their opinions to recover what you’ve already earned.  If the findings are significant enough, you may lose further credibility as your patients review your metrics on the Physician Compare website or other social media. You have provided extraordinary service, yet your reputation still be smeared in the eye of public opinion.

4. What Options Do We Have?

The primary reason many physicians find themselves in adverse situations, is they are so focused on saving money on the “price” of the billing service, they take their eye off the ball of the “total cost” of that choice. By saving 1.3% on the front end, many physicians are easily losing 5% to 10% and therefore, there is no true billing company cost savings. The actual total “cost” of billing can be 15%, 20% or more.  (We’ve seen this multiple times as we’ve had the opportunity to work with new physician groups who had no idea they were losing so much money.)

Why do physicians defer making the choice to change their situations? Because it’s not easy. It also involves the risk associated with change.

The question becomes, “What will give me the confidence to take the risk to make a change in my billing process?”

  1. Getting a legitimate assessment of what you should be receiving today based on your current demographics, volumes and payor contracts.
  2. Taking a little time to get beyond the sales hype of billing companies and finding out how they really perform and how you can monitor that performance.
  3. After you’re convinced you’re leaving money on the table and you’ve identified a good billing company, get confirmation by spending time talking with several of the billing company’s physician clients. Ask the hard questions. Performance. Yield. Physician Education. Coding. How they validate they receive all your interpretations. How they validate payor performance. You name it. Ask them. Ask us.

You have NO risk in taking step number 1 above. We will provide a confidential assessment of what your group “should” be receiving based on your current demographics, volumes and payor contracts based factually on HealthPro’s current actual performance of like data.


Step 2 involves further due diligence such as getting the independent assessment in step 1. In addition to this step, ask the tough questions and demand comparative metrics.

If you discover and confirm you are already receiving what you should and your compliance risks are minimal, you have received a free confirmation that will give you more peace of mind.

After the first two steps, if you discover you are leaving money on the table, you can take the next step and confirm a prospective billing company’s performance by talking with directly with their physician clients. Then and only then, can you move forward in your decision to change with confidence.

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