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 practices).

• Not billing 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 measured by:

• Provider training and education provided

• Value of compliance resource materials provided

• Compliance within payer guidelines of claims submitted to payers.

This is equally true for in-house billing as well as third party claim processors/billers.

Inefficient billing 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 Provided

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 appropriate payer.)

Pricing

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

• Cost Plus

• Monthly Flat Fee

• Percentage of Receipts Collected

• Blended Rate (Combination).

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.

Measuring Success

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 service.)

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 appeals, etc.
  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 practice.

• "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.

• "100% Guarantees": 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 by Cigna® 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 individualized.
  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 existing service.
  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 companies.

We 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.

Surgical Assistant 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.

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.

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