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Advice You - Outsourced Medical Billing Software and Service Selection in 14 Steps
Over four thousand vendors of medical billing services offer solutions to medical practices nationwide in response to poor in-house billing performance and increasing regulatory scrutiny of billing processes. On one hand, such a large number of outsourced billing solutions ensure continued competitiveness in terms of both service quality and pricing. On the othe
According to USFDA, a combination product is one composed of any combination of a drug and device; biological product and device; drug and biological product
r hand, the lack of uniform service standards and metrics among the vendors, combined with their large numbers, makes the process of vendor selection difficult and error-prone. While the availability of a large vendor selection allows finding an alternative to unsatisfactory service, billing vendor-switching costs remain high, motivating extra effort and focus du
; or drug, device, and biological product and fixed dose combination would include two or more combinations of drug.
Examples of combination products may in
Examples of combination products may in
ring the stage of vendor selection. This article outlines basic thirteen-step guidelines for an effective and efficient medical billing vendor selection process.
1. Scope of Services
Decide if you are looking for billing technology, billing service, or practice workflow solution. If you plan to manage billing in-house, you may only need a billing tech
1. Scope of Services
Decide if you are looking for billing technology, billing service, or practice workflow solution. If you plan to manage billing in-house, you may only need a billing tech
lude drug-coated devices, drugs packaged with delivery devices in medical kits, and drugs and devices packaged separately but intended to be used together.
nology solution. In that case your next decision is whether you wish to own the technology or to rent access to it.
Complete practice workflow solution belongs to the other end of the spectrum of services and starts with appointment scheduling and includes electronic medical records, SOAP notes, and billing. Few vendors today offer such integrated packages as th
Complete practice workflow solution belongs to the other end of the spectrum of services and starts with appointment scheduling and includes electronic medical records, SOAP notes, and billing. Few vendors today offer such integrated packages as th
here is enormous increase in the number of combination products entering the market in the recent years. Combination products have proven advantages but fixe
ey require powerful vericle-like technologies used by trained and skilled personnel implementing rigorous and disciplined service processes.
A billing-only service belongs to the middle ground between the choices described above and may include coding, electronic claim submission, "scrubbing" (validation), payment posting, claim and payment reconciliation, follow
A billing-only service belongs to the middle ground between the choices described above and may include coding, electronic claim submission, "scrubbing" (validation), payment posting, claim and payment reconciliation, follow
d dose combinations are still in the process of convincing regulatory authority on their advantages over the single ingredient formulations.
Combination pro
Combination pro
up, secondary submission, and patient billing.
2. Billing Model
Billing model selection is the second most important decision in your definition of desired vendor. What is the policy of followup process prioritization? Who decides on which claims to followup? Which of the following functions are automated: upfront claim validation, submission, reconc
2. Billing Model
Billing model selection is the second most important decision in your definition of desired vendor. What is the policy of followup process prioritization? Who decides on which claims to followup? Which of the following functions are automated: upfront claim validation, submission, reconc
ucts have become life saving products for the pharmaceutical companies who doesn’t have many innovative molecules in their product pipeline and have been inc
iliation, and follow-up workload allocation?
3. Reporting and Transparency
Transparency is a critical aspect of outsourcing billing service because without transparency the service may not be reliable. To be able to observe every step of the billing process on a continuous 24 x 7 basis, reporting must be available using a secure HIPAA compliant connecti
3. Reporting and Transparency
Transparency is a critical aspect of outsourcing billing service because without transparency the service may not be reliable. To be able to observe every step of the billing process on a continuous 24 x 7 basis, reporting must be available using a secure HIPAA compliant connecti
easingly used in the product life cycle management. Even the companies having product patents are trying to extend their product life cycle through the combi
on over the Internet.
The ability to provide timely and useful reports depends on billing model (see above) and billing technology. Vendors that manage their own billing technology typically have better control of reporting capabilities in terms of scope, analysis, frequency, and transparency. At the minimum, the following features must be available:
The ability to provide timely and useful reports depends on billing model (see above) and billing technology. Vendors that manage their own billing technology typically have better control of reporting capabilities in terms of scope, analysis, frequency, and transparency. At the minimum, the following features must be available:
- Denials Report shows the list of denied claims and a log of followup actions. By sorting it by amount paid, you can tell the smallest payment
- Compliance Report shows the potential for post-payment audit and itemizes compliance violations.
- Reporting Frequency defines the data update intervals on existing reports and turnaround time for new reports.
- Data Aggregation and Analysis must allow arbitrary
nation products and maximize the revenues. But the companies involved in this practice are overlooking that they are burdening the patients both economically
i> 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.
and physically. They need to rightly judge the benefits of the combination products and they have to even look at the risks involved when combining the produ
the billing service will fight for.
ts. Some of the combination products were well accepted by physicians while others suffered. Companies involved in development of combination products are fi
data aggregation and drill-in. Export to Excel spreadsheets for further analysis is a very useful feature.
4. Certification
Request formal certification of compliance with basic regulatory requirements. Stay away from national vendors with New Jersey clients or New Jersey vendors without formal certification from New Jersey Department of
4. Certification
Request formal certification of compliance with basic regulatory requirements. Stay away from national vendors with New Jersey clients or New Jersey vendors without formal certification from New Jersey Department of
ding difficulty in defining their combination products and facing various challenges from selecting a combination to marketing it.
Following aspects would a
Following aspects would a
Banking and Insurance.
5. References
Ask for a list of references owning similar practices. Are the clients satisfied with results, support, and changes over time? Can they quantify billing service quality in terms of Accounts Receivable over 120 days and underpayment reduction?
6. Billing Service Quality
Make a list of metrics used by the
5. References
Ask for a list of references owning similar practices. Are the clients satisfied with results, support, and changes over time? Can they quantify billing service quality in terms of Accounts Receivable over 120 days and underpayment reduction?
6. Billing Service Quality
Make a list of metrics used by the
dd to the challenges in developing combination products:
Which markets to tap where the combination products can do fairly well?
Which combination prod
Which markets to tap where the combination products can do fairly well?
Which combination prod
service. Focus on collections completeness and payment delay. Can the vendor quantify the differences between payers and between various CPT codes in real time? Does the vendor follow up every denial? What is the denial followup success rate?
7. Compliance
Consider two aspects of compliance, namely, your practice and billing service. Request to re
7. Compliance
Consider two aspects of compliance, namely, your practice and billing service. Request to re
cts are meaningful and rational?
Which therapeutic categories to select?
Which Combinations can address unmet needs of the patients?
Do combin
Which therapeutic categories to select?
Which Combinations can address unmet needs of the patients?
Do combin
view a written compliance program for the billing service. Ask for its update procedure. For your practice, request an interface to a legal service specializing in post-payment audit risk management.
8. Communications Protocols
A disciplined vendor has a formal and simple process to report problems and track their resolution. Your practice must have
8. Communications Protocols
A disciplined vendor has a formal and simple process to report problems and track their resolution. Your practice must have
tions increase the patient compliance?
What would be the developing cost?
How to tackle the risks encountered during combination product developmen
What would be the developing cost?
How to tackle the risks encountered during combination product developmen
a competent account manager and regular meetings scheduled to review outstanding problems.
9. Data Security and Protection
Review data center facilities. Ask for evidence on HIPAA compliance: claims must be viewed only on the "need to know" basis, access to claims and modifications must be thoroughly documented. Data must be protected with redundant
9. Data Security and Protection
Review data center facilities. Ask for evidence on HIPAA compliance: claims must be viewed only on the "need to know" basis, access to claims and modifications must be thoroughly documented. Data must be protected with redundant
t?
As combination products don't fit into the traditional categories of drugs, medical devices, or biological products, the USFDA is in the process of devel
As combination products don't fit into the traditional categories of drugs, medical devices, or biological products, the USFDA is in the process of devel
disaster recovery measures. Review backup process, backup intervals, and data restore capabilities.
10. Data Entry Protocols
Modern technologies allow the doctor to take over coding and reduce the billing role down to claims processing and followup. Technology-competent vendor will supply your superbill online, along with a separate form for patient
10. Data Entry Protocols
Modern technologies allow the doctor to take over coding and reduce the billing role down to claims processing and followup. Technology-competent vendor will supply your superbill online, along with a separate form for patient
ping new procedures for reviewing their safety, efficacy and quality.
Professional from academic institutions, pharmaceutical industries, health care indust
Professional from academic institutions, pharmaceutical industries, health care indust
and charge entry, EOB posting, and on-line claim editing. Similarly, much of data entry validity, including some of claim scrubbing will be done online at the point of data entry.
11. Processes for Continuous Improvement
A successful vendor must have developed an effective process to identify and resolve systemic errors. Without such a process, the ve
11. Processes for Continuous Improvement
A successful vendor must have developed an effective process to identify and resolve systemic errors. Without such a process, the ve
y and representatives from various regulatory agencies are working out to design the regulatory requirements for manufacture and sale of combination products
ndor will lose competitiveness and you will have to switch the services at a later stage.
12. Size and Scalability
Automation defines scalability. The more steps are automated, the easier it is for the vendor to take on new clients without impairing service quality. To understand vendor's scalability, you must compare gross annual billings, claim volu
12. Size and Scalability
Automation defines scalability. The more steps are automated, the easier it is for the vendor to take on new clients without impairing service quality. To understand vendor's scalability, you must compare gross annual billings, claim volu
.
As there is an increasing trend of the combination products companies manufacturing such products should be able to tackle the problems involved in the de
As there is an increasing trend of the combination products companies manufacturing such products should be able to tackle the problems involved in the de
mes, and numbers of doctors. Avoid vendors that would have to treble their scale because of serving your practice.
13. Staffing
Review staff numbers, educational background, experience, and reporting structure. Understand the process of quality assurance and accountability. Avoid vendors that would have to double their staff to serve your account.
13. Staffing
Review staff numbers, educational background, experience, and reporting structure. Understand the process of quality assurance and accountability. Avoid vendors that would have to double their staff to serve your account.
elopment. They need to be wiser in analyzing the market trends and the regulatory requirements.
Companies that provide selfless information through particip
Companies that provide selfless information through particip
14. Pricing
Most billing service vendors charge a percentage of monthly collections. This percentage varies across specialties, depending on the average claim billing size and claim volume. Note that the lowest cost provider is not necessarily the best. Read our companion article on relative value of billing quality and price-performance relationship.
Most billing service vendors charge a percentage of monthly collections. This percentage varies across specialties, depending on the average claim billing size and claim volume. Note that the lowest cost provider is not necessarily the best. Read our companion article on relative value of billing quality and price-performance relationship.
tion in industry events and feedback to regulatory authorities would be able to face the challenges and will be successful in developing combination products
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