In-House Billing versus Outsourced Billing: Making the Best Decision for Your Practice
CODING
Brandy Brimhall
A common topic of interest in chiropractic practices includes the billing department and whether the primary duties of insurance claims submission should be kept in-house or outsourced to a professional billing service. Multiple factors weigh in on this topic, and rightfully so. Providers should consider the following factors:
Employee Role: Do you have the right person or people for this job? While data entry, coding, billing, collection, and follow-up systems can be taught, the duties and responsibilities of this role must never be taken lightly. Those in charge of this department are second in line to the doctor in keeping the practice’s doors open. Additionally, the understanding and correct application of guidelines, attention to detail, efficiency, integrity, and communication skills necessary to manage this role will serve as significant protection for your practice.
Training: What tools do you utilize to ensure proper training of your billing personnel? On-the-job training is always beneficial, particularly for the actual systems and procedures necessary for each role. However, when it comes to billing and claims submissions, other essentials must not be overlooked or disregarded. These include some of the following: proper use of codes (CPT, ICD-9/ICD-10, HCPCS, modifiers); how
“ While data entry, coding, billing, collection, and follow-up systems can be taught, the duties and responsibilities of this role must never be taken lightly. J J
to read EOBs (explanation of benefits); general understanding of documentation guidelines and how appropriate codes are determined; handling claims follow-ups and resubmissions; responding to payer inquiries and requests for information; and more.
Hopefully, you aren’t thinking that because there are fewer codes used in chiropractic than in other specialties, then adequate training for chiropractic practices isn’t as necessary. If you do think that, then you must understand that penalties for errors and noncompliance with regulations apply to all specialties. It is not any less critical for chiropractic practices to have a clear understanding of code definitions, guidelines for proper billing and collections, and other items as previously described.
Time Management: Does your practice have the time available to manage this department properly? Billing and collections are not come-and-go duties to be handled intermittently or “when time allows.” A lack of time and attention spent with the responsibilities of this department will result in oversights, errors, and loss of revenue.
Audits: The Office of Inspector General (OIG) has made it clear they will continue to focus on fraud and abuse. Due to this, as well as continued success in audit recoupments, both government and private payer audits continue to rise dramatically. There is no secret to guaranteeing that your office will never be audited, regardless of the type of practice you have. One important tool for audit prevention is the proper management and maintenance of your billing department.
In-House Billing:
Pros:
With the right staff member managing this department, there are many benefits to keeping your billing in-house. It can be easier to manage and monitor, allowing the provider to have some comfort in being able to see what’s taking place in the billing department on a moment’s notice. Many providers prefer to maintain control of this portion of the practice. There is also the benefit of allowing for a more efficient and much easier method for the billing personnel to communicate with the doctor(s) as needed. Communication between the biller and provider is extremely important. Not only can communication minimize documentation and billing errors and oversights, it also can improve efficiency in billing and follow-up systems. Since many chiropractic offices do some degree of cross-training, the billing personnel also may be able to help in other areas at times.
Cons:
Inadequately trained staff, lack of available time, or even just having the wrong person handling this role will likely become an expensive deficiency for your practice. Obstacles, such as uncertainty and assuming instead of checking, will always lead to errors. When practices are unprepared or unable to competently manage billing systems in-house, it can also lead to having inefficient billing systems and/or billing frequencies, inadequate collection systems, an inability to read and understand EOBs, lack of follow-up and general claims management, miscoding, etc. Unfortunately, any of those increase the likeliness of some form of an audit, recoupment of payments received, and potential allegations of fraud and/ or abuse, and more. Additionally, practices can experience a lack of cash flow due to incorrect billing, inadequate follow-up systems, and denied claims, and as a result, find their patient relationships on shaky ground. As you would expect, this can begin a domino effect of hindrances for a practice, such as lack of referrals, patients not returning for care, etc. Clearly,
“ A professional billing service will often be managed by or employ certified coders and even sometimes certified billers. 5 5
long-term occurrence of issues such as these can be suffocating to a practice.
Moreover, too often the person handling the billing department is the only one who knows what to do or what is going on with that part of the practice. Not only is that a huge liability to the practice, but it will become an even bigger issue if your billing person resigns, takes a vacation, etc.
What you should expect from your in-house billing personnel:
The billing department in your practice is truly one of the more difficult departments for a provider or owner to monitor. Statistics and accounts receivable reports are the easiest ways to regularly monitor the productivity of your billing department. Known schedules and systems are important to have in place as well. This means that not only should your biller know what he or she is doing on any given day, the doctor/owner should be aware of this too, not only for accountability purposes, but also as a way to understand the flow
and systems in this department. White boards are one way to allow billing department duties and systems to be monitored at a glance. Regular meetings and open communication with the practice’s biller should also be expected. This should come in the form of regularly scheduled meetings and an open-door policy for as-needed questions and discussions. Finally, providers/owners should expect written procedures identifying billing system protocols so that the role can be more easily trained or filled if needed.
Outsourced billing:
A professional billing service will often be managed by or employ certified coders and even sometimes certified billers. These individuals have had to learn the fundamentals for coding, billing, and documentation, and have been tested on practical application of these guidelines. Additionally, they must have a certain number of continued education hours each year or two to retain certifications. While that doesn’t guarantee that a practice’s billing will take place without error, it should offer significant confidence to a practice that the people managing its claims have competence, adequate training, experience, and understanding of rules and regulations pertaining to the components necessary for proper billing.
Outsourced billing services are defined as “business associates” by HIPAA. The HIPAA Omnibus Rule of 2013 has placed more responsibility on these business associates for maintaining compliant business practices. In general, this includes the HIPAA Breach Notification Rule, Security Rule, Privacy Rule, etc. It should comfort providers to know that their professional billing services are held to a very high standard of expectation.
In addition, a professional billing service’s primary responsibility is to manage claims billing and collection systems. This means that they will have effective systems in place to appropriately manage claims for each of the practices they service.
A billing service is usually paid a percentage of the insurance payments it generates. This means they are going to work as hard as possible to ensure those needs of your practice are properly handled.
A good and reliable billing service will function like a well-oiled machine. Systems and procedures will be in place to make a practice’s insurance billing and collections as efficient as possible.
Cons:
Without proper systems in place, communication between the practice and billing service can be minimal. This can and will likely result in oversights, errors, and miscommunication. It is more difficult for a provider to monitor productivity of an outsourced billing service, which results in the provider feeling uncertain and lacking in control of this area of his or her practice. Delayed claims, denials, and even late claims submissions can become a factor as well. Often, a billing service may need more information from a provider before a claim can be submitted, but with weak communication systems, these claims can sometimes sit untouched for long periods.
It can be difficult to find a reliable and reputable billing service. Providers occasionally have had less than optimal experiences with a billing service, and as a result, they have vowed to avoid outsourcing their billing in the future. Most often, this unfortunate experience is due to providers and billers not having the right kind of discussion when agreeing to work together, and therefore, not fully knowing what to expect from one another or what is expected of each entity. Lack of regular communication can be damaging to these business relationships as well.
What you should expect from your outsourced billing service:
A provider should be able to monitor his or her billing service by statistics and with communication. At a minimum of once per month, your billing service should provide stats to the practice for evaluation. Many billing services provide weekly or semimonthly reports, which are even more beneficial for providers. This allows the provider to monitor billing and collections, see progress as time progresses, and have comfort and confidence in the handling of this role.
Open communication should also be addressed to allow billers, providers, and the practice’s employees to regularly connect, ask questions, discuss obstacles, address issues, and collect missing information.
Ideally, a provider would be able to monitor this off-site department in his or her practice similarly to the way the provider would expect to do so, as if eveiything were being handled right within the walls of the practice. With appropriate systems in place, it can be accomplished.
Ultimately, there is no wrong choice when weighing the options of keeping your practice’s billing in-house or outsourcing it to a professional service. The right choice for you is going to be what you determine is the best fit for your practice.
Whether the practice’s billing department is in-house or outsourced, the bottom line is that providers should not be blind to the roles, responsibilities, duties, and systems of his or her billing department. These are the perfect ingredients for a very vulnerable provider.
References:
http://www.hipaasurvivalguide.com/hipaa-omnibus-mle.php
http://www.hipaasurvivalguide.com/hitech-act-13408.php
http://oig.hhs.gov/reports-and-publications/archives/workplan/2015/F Y15-Work-Plan.pdf
Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA
ChiroCode Institute Director of Education
www. chirocode. com
602-944-9877
