Before you proceed any
further, let us give you some advise; if you already have a billing
service and is presently satisfied with their results, pricing and ethical
practices, we sincerely recommend to keep that relationship, as these
companies are extremely hard to find. Now, if you are not satisfied with
the results that you are receiving and/or have questions about their
ethical practices, then read on...
The medical industry has continued to change at an
incredible rapid pace, the function of surgeons and non-physician surgical assistants
and obviously its billing practices has evolved to a complex process requiring highly trained personnel and excellent continuing education for
surgeons, assistants and their
claim processors and/or billers to assure accurate and timely reimbursement.
Due to the increased administrative burden associated with managed care and other third-party payer reimbursement processes,
surgeon's practices, surgical assistant groups and independents are finding it increasingly difficult to devote the necessary time to optimally manage their accounts receivable. Computer software alone cannot be counted on to reverse the present trend of dwindling cash flow. One result of this trend is that many practices across the country are focusing more attention on finding the best billing service to improve compliance management and address shrinking revenues. Finding the right billing service for your group
or yourself involves a study of not only existing operations, but also expectations, requirements and qualifications of any billing service being considered.
How Much Will it Cost?
One of the first questions that comes to mind when thinking about
outsourcing to a billing company is: How much will it cost?
The true cost of billing
must include the loss of revenue or expense from :
Procedures that did
not match with the codes, your surgeon used, (surgical assistant
procedures appropriate to bill
Claims not appealed
Write-offs that could
have been collected
And all direct and
indirect billing fees.
Compliance risk can be
and education provided
Value of compliance
resource materials provided
payer guidelines of claims submitted to payers.
This is equally true for
in-house billing as well as third party claim processors/billers.
methods, poorly trained staff or inadequate supervision can cost a
significant amount of revenue. The revenue loss takes on even greater
significance in light of shrinking reimbursement schedules associated
with the managed care environment.
Billing effectiveness must be included in any evaluation formula, and a
means by which to objectively measure billing performance should be in
place prior to the execution of a billing-company agreement.
Spectrum of Service
Various levels of service are available from third-party billing
entities. It is important to be sure you are comparing "apples to
apples" in the breadth and depth of services provided and relate these
to the fee charged by the billing company. For example, some billing
companies charge additional fees for postage or other elements of the
billing process. Thus, you need to understand any add-on fees and
include these when comparing the total fees of each billing company.
Also, you should compare how much insurance follow-up will be done on
your accounts by each company to be certain that one company doesn’t
simply "skim" by focusing on easier to collect dollars while largely
ignoring the more difficult to collect dollars.
Finally, make a list of your important needs and expectations on issues
such as office staff, surgeon and assistant training and feedback, billing reports, and payor
experience to determine which billing company best meets
these needs and expectations.
Add the Value of
Non-revenue Services and Objective Quality Indicators
Collecting your money is
only one function of a good billing company. The company may also offer
valuable compliance and training services that should be factored into
your decision. For example, one compliance violation can result in fines
up to $25,000 and result in your removal from a program. You are
accountable for compliance violations even if the billing company does
your coding. Some companies provide surgeon and assistant training in reimbursement
and compliance-coding issues, as well as programs to help your group
avoid costly fines. Quality, defined by objective criteria such as the
company’s percentage of "clean claims," also has tremendous bearing on
your cash flow and your bottom line. (A clean claim can be defined as a
complete and accurate claim submitted in a timely manner to the
It is important to evaluate your billing company based on value rather
than price, because the price you pay is less important than what you
get in return.
The question to ask is, "What will our bottom-line collections and
compliance risk be, after paying for your billing services?"
Not all billing companies price their services in the same manner.
Some of the more common pricing scenarios are:
Per Claim Basis
Monthly Flat Fee
With so many pricing models and variables, it is essential for valid
comparisons to ask each prospective billing company for a reimbursement
analysis as described below.
The billing industry
exhibits varying measurements for success. One widely used but
misleading measurement is the collection percentage. This is an
unreliable number when used in isolation, because so many variables are
at play such as the group’s payer mix, fee schedule, and acuity profile.
For example, it is not the same to bill for a licensed surgical
assistant in Texas or RNFA that to bill for a CSA in Nevada or Arizona.
The most meaningful measurement standard is the actual payment received
per procedure in your specific state and your credentials. This
measurement allows you to compare the results of different billing
companies without misleading influences such as an inappropriately low
fee schedule. (The way to achieve a 100% collection rate is to lower
your fee schedule to the rate the lowest payer will reimburse each
Be aware of the following
tactics that have been used by some billing companies
to get your business:
"Success Kits": The
success kits consists of sample letters, sample contracts, sample
The truth is that all of these documents can be obtain in the
internet for free, and if a billing company is serious about their
business they will not charge you a cent to guide you through the
process of going independent and provide sample documentation for
your business, including HIPAA regulations. However, even though we
provide these same sample documentation to our members for free, we
truly believe that appeals and contracts are unique to the provider,
insurance and facilities involved, it is your business and financial
well-being on the line and these documents should be unique to your
circumstances, and we help you make those documents unique to your
"Top Secret Pricing":
Have you noticed that most of the billing services out there do not
publish their pricing structure? They ask you to call them for more
information. Although, they might argue that this is done to prevent
the competition to know how much they charge and beat their prices,
the truth of the matter is that this is unfair to the client. You
have the right to know beforehand what are the fees involved and the
pricing structure, regardless of your volume and/or procedure mix.
There are only a handful of States that have legislation in place
regarding reimbursement for non-physician surgical assistants, and
only Physician Assistants and Nurse Practitioners are recognized by
the Federal Government for this role as providers. This means that
if your state does not have any legislation regarding reimbursement,
there is no guarantee that you are going to be reimbursed
accordingly, especially if a company guarantees a percentage.
Without provider agreements, reimbursements can vary widely within
the same insurance company and within the same procedure. The reason
is simple; claims are paid according to insurance adjusters and each
one has different ways of evaluating claims and ways of interpreting
their employer's payment guidelines. For example; you might get paid
for a Laparoscopic Cholecystectomy and get denied for the same
procedure by them the following month, and you cannot appeal
claiming that they paid in the past, because they might want a
refund of the previous claim, so your collection effort should
If you are a non-physician surgical assistant and are consistently
reimbursed at a rate that is 20% or higher of the surgeon's fees on
every single claim, you might want to check your billing service's
billing practices, as they might not be quite ethical, and you might
be liable in case of an investigation.
We have heard assistants that are very "proud" and satisfied with
their existing billing company because they are getting a consistent
high reimbursement rate in a State that does not have legislation
and taunt that their billing service has a "pit bull" approach. If
done ethically, it is a process that we have to admit we haven't
figured out after 9 years processing approximately 28,000 claims for
surgical assistants, and we sincerely recommend to stay with their
Remember, non-physician surgical assistants frequently get
reimbursed more than 20% of the surgeon's fees, especially by
worker's compensation claims, who often reimburse at 100% of billed
amount and some private payors such as BC/BS of Illinois, who
reimburse at 22% (Starting in 2005 they will reimburse at 16%, due
to provider agreements), however this should not be the norm,
what we are referring to is a consistent pattern with ALL insurance
are seeking long term client relationships, and in SurgBill, Inc. we
believe that being honest and upfront to our clients about their
expectations is key in building that relationship. We do not believe in
false marketing and promises that cannot be kept to gain your business.
Billing Company Evaluation
The chart below will help you compare billing companies before selecting
a partner for your group or individual billing needs.
Place a checkmark in the
column of the company that exhibits superiority for each attribute and
incorporate the results in your decision.
company specialize in the unique reimbursement needs of
surgical practice professionals?
Are you confident in the company’s pricing
the company’s percentage of "clean claims"?
employees have a confidentiality agreement on file?
Is the company’s
Information System and computer software compatible with
Does the company
provide all of the relevant reports you need to effectively
manage your group’s revenue?
Does the company
offer compliance assistance to help your group adhere to
regulations and avoid costly fines?
the company optimize cash flow and minimize time lag between
procedure and billing?
Does the company partner with you to help you manage your
revenues and compliance risk?
Are the billing
company’s top officers exceptionally qualified and highly
accessible to help you with group reimbursement concerns?
Does the company have leadership and oversight from
experienced surgical assistants who understand
your reimbursement issues and compliance concerns?
Does the company provide assistance
in evaluating and managing your contracts with payers?
If your answer is "no" to any of these
questions, you owe it to yourself to discover how SurgBill, Inc. can put you and
your group on the path to optimized reimbursement performance. Contact
us at (815)464-2953 if you live within the Chicago area or our
toll free number at (866)234-2678 if calling within the US, or send us an e-mail
today. It could be the most profitable move you’ll ever make.