A Medical Billing Business – What to Look For

If you are a physician looking for a medical billing business to handle your accounts and insurance claims, there are a few things that you need to bear in mind. Remember, this is not just another job; this is the bottom line of your practice! If billing is not done correctly it will cost you dearly.

As a physician you are not trained to do accounts, and you should really stick to what you were trained to do, take care of your patients. There are people who have undergone training in order to do medical coding and billing, and these tasks are best left to those individuals who know how to do them and who enjoy doing that kind of work. Whether you just have a small practice or an established one, getting a medical billing business or an individual who does medical billing and coding to handle your billing is the right thing to do.

By using a medical billing business you will be able to see your collection ratio increase greatly. Third-party medical billing services are fast becoming the industry standard. Medical billing professionals use various skills to complete claims on behalf of hospitals, physicians, outpatient facilities and other various other medical procedures. Medical billers and coders are responsible for understanding, coding and organizing medical data to ensure the accurate record thereof, and the data capturing thereof.

Although medical biller’s duties will vary slightly from practice to practice, typically they will handle all data concerning the bill. This means that they ensure that all medical data is recorded, all insurance forms are completed and signed and submitted to the relevant companies for payment. Medical coders and billers also regularly communicate with physicians and other healthcare professionals in order to obtain additional information or to clarify diagnoses. In order to be able to so this the coder/biller must know how to read medical invoices and must be familiar with the HCPCS Level II, CPT and ICD-9-CM codes.

Apart from capturing medical data and preparing invoices, a medical biller will also very often contact patients in order to access delinquent payments, or to resolve billing errors. They also do collections, make adjustments, handle denied claims, interpret Explanation of Benefits (EOBs), and process appeals.

Depending on the size of your health care business, you can either engage the services of an established and professional medical billing business which provides the whole gamut of medical billing services, or you can hire an individual that has their own home-based business. Some smaller businesses and individuals may limit their services to only specific billing-tasks, whilst a large practice management company will deliver a comprehensive range of services, including marketing and scheduling assistance.

What to Expect from a Medical Billing Business

A medical billing business offers you a way to outsource the increasingly complicated and time-consuming administrative tasks associated with insurance and patient collections. There are essentially three levels of medical billing services, and the following should give you some idea of which type or level would best suit your needs.

Services that you may expect to receive when signing on with a medical billing business are:

Basic Billing Services

  • Insurance claim submission: Medical billing is done via specific coding which needs to be forwarded to the insurance companies for payment. The service provider generally utilizes specific electronic billing software to transmit data regarding a patient’s demographic, insurance details, and details regarding the patient’s visit to the insurance carrier.
  • Insurance follow-up: Many physicians and smaller clinics have problems with non-payers, but do not have the time or resources to follow-up on defaulters, which his where a third-party medical billing business becomes a very valuable partner in the business. These businesses generally are very tenacious and are experienced in following up on claims with the insurance carrier, which boosts the reimbursements.
  • Patient invoicing and support: Physicians do not have time to field billing queries, so al the logistics of making up the bills, posting them and handling patient inquiries is done by the billing service.
  • Reporting and analysis: Billing services will typically prepare one or more monthly reports in order to keep you apprised of any problems and will also offer sage advice as to how to increase profitably. These reports generally offer a customized look at certain key metrics that help the medical profession to identify strategies that will help the practice to grow, save costs, and get better returns on billings.

Extended Billing Services

  • Credentialing: Credentialing services handle all the administration involved in initiating a relationship with a new insurance carrier; something no physician really has time for and gladly hands over to a third party.
  • Medical coding: Some individuals who offer billing services and some billing business will only handle the billing side of the services, but others will offer additional services such as the actual coding of the diagnosis in preparation for the data entry into the medical billing software program. This is an integral part of the billing process and needs to be done very carefully by someone who knows, understands and if current with all of the medical codes used for various diagnoses and drugs used in treatment.
  • Transcription: This is also an additional service offered by a medical billing business or individual, and precedes the coding portion. Transcription is also done by an individual who is familiar with medical terminology and can transcribe from notes and audio tapes made by the physician and enter the information into the patient’s file. Most patient records are kept digitally these days, so transcription and data processing is an integral part of managing a patient’s history.

Practice Management Services

  • Contract negotiation: Smaller private practices and lone physicians do not usually have the time or the resources to negotiate with managed care representatives. Practice management companies have the knowledge, resources and expertise to negotiate effectively on their clients’ behalf.
  • Financial services: A medical billing business does not only handle the actual billing or insurance claims collections, but often also offers full practice management financial services. These services can include bookkeeping, budgeting, tax planning, and accounts payable.
  • Human resource services: Staffing matters, benefits program design, employment contracts and payroll can all be outsourced to a full-service medical management service.
  • Protection and Affordable Care Act: Specialists in medical billing are very knowledgeable in all things billing, and are therefore in a good position to be able to spy loopholes and can apply their technical skills to identify and resolve billing concerns before they arise.

Those in the medical billing business have studied and understand the human anatomy and how the human body works. They are also knowledgeable about drugs and the medical terminology used. This knowledge is vital to enable the service provider to file claims with insurance companies that include the apropos coding for specific diseases, conditions, and procedures.

Another important aspect of medical billing is the understanding of the Health Insurance Portability and Accountability Act. Individuals involved in medical billing and coding must stay abreast with all changes to the American health system, and also be up to date about the most current codes, which change constantly as new medications come on the market or new conditions occur.

Outsourcing the administrative side of a medical practice relieves the physician from having to worry about staying abreast of all these administrative factors that actually have nothing to so with the medical side of the practice.

What to Look For in a Medical Billing Business

Selecting a medical billing business is like looking for a business partner and should be done carefully in order to guarantee a successful partnership, whether you are seeking the services of a large full-service company or just the basic services of a home-based biller.

Key factors to consider when searching for a medical billing provider:

  • Experience or Training: Ask for a resume detailing their credentials, training they have done in the specialties that you require, and what if any coding training and experience they have.
  • A provider that has been around for a while is good as it shows that they have experience in the field. Do not let the lack of experience put you off though, as a newly qualified biller may not have that much experience, but they will definitely have the latest knowledge and information and will be current with their codes, methods and technical programs. Small billing companies or individuals may suit your business better as they can provide a more personalized service. These businesses know what it takes to satisfy and keep clients happy, and they usually rely on personal references and word of mouth to grow their business, so will deliver only the best service.
  • Staff Complement: Ensure that the billing provider that you engage has a large enough staff complement to deal with the number of claims that you will be submitting.
  • HIPAA Regulations: Is the medical billing business compliant with HIPAA regulations? What is their HIPAA policy? It is dangerous to supply a company that lacks the appropriate security measures with a patient’s information. Also query any training they give their personnel in this regard. Make sure that they have safeguards in place for security of data backup.
  • References: References from satisfied clients are always a good way to judge how good a business is. If they are a new business and do not have many references yet, ask for references from teachers, course instructors, Association Directors, or previous employers.
  • Reports: Ask them what types of reports they will provide you with and whether these reports are done monthly, quarterly or annually. Some of the basic reports that you should insist on are:

    • Accounts Receivable: Can be aged by either date of entry or date of service
    • Claims Report: Shows claims submitted for that reporting period
    • Managed Care: Show loss of revenue, timely payment, adjustments, and referral tracking
    • Practice Analysis: Overall reporting of practice charges and receivables
    • Transaction Report: General report of charges, payments, and adjustments

  • Collection Practices and Procedures: Ask them what their practices and procedures are; do they alert you to take action on delinquent accounts or do they provide soft collections?
  • Claims and Appeals: Inquire as to how they will follow up on claims and what their appeals procedure is.
  • Fee Structure: A medical billing business can charge for their services in various ways, and it is important that you ascertain how their fees are structured before you engage their services. They will generally evaluate your practice and needs before providing you with a quotation. Some business bill a flat monthly fee, others bill per patient, and some bill on a percentage basis. If it is based on a percentage, find out whether it is a percentage of total practice collections or total charges billed. Is there a start-up fee involved? Some states have laws regarding fee-splitting, so make sure that you know what the laws in your state are regarding this before entering into any contract with a billing service.
  • Software Programs: Depending on the kinds of service that you require from the medical billing business, various software programs are used. Ascertain whether they can provide you with remote access and/or a read-only copy to assist your office to collect appropriate co-payment amounts. Discuss what solutions are available for you to access your account at your practice. Ensure that your office is also HIPAA compliant and that your computer has reserved access for all confidential records.

Only you can determine whether you should outsource your medical billing, and the type of medical billing service that you should outsource. This industry offers a much-needed service and the services that are provided can have a major positive impact on the medical office workload, on your revenue and expenses. By doing thorough research and taking your time to ascertain the type and range of services that you require and can afford, you will be able to make an informed decision as to which medical billing business you should use.

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