Arcane terminology and complex rules for payer- and time-dependent claim validity and pricing interpretation plague medical billing industry, resulting in massive payments of invalid or ineligible claims and denials of error-free claims. The amount and complexity of billing information make it very difficult for the doctor to maintain compliance and identify and resolve errors and underpayments.
"With integrated Billing Transparency, I see for myself how Vericle leverages every opportunity to expedite payments of healthcare insurance claims in a continuous 24 x 7 effort. It has enabled 27% revenue gain over past billing process, " says Doug Cassel, M. D. , Director of Interventional Radiology at Hoag Memorial Hospital in Newport Beach, California.
Greater visibility of internal process activities promotes teamwork, increases client satisfaction, and assists in process streamlining. Billing service transparency allows participants of the billing process to expedite error identification and resolution, resulting in reduced over- and under-payments and improved regulatory compliance.
1. Billing Dashboard as Main Transparency Mechanism
Selection of meaningful and intuitive indicators for billing process performance is a mission-critical stage in the process of creating a useful transparency mechanism. A dashboard presenting such most meaningful data must be easy to find and simple for interpretation. Cumulative experience of hundreds of doctors using Vericle-like billing technologies, has shown that a dashboard containing nine specific indicators expedite the development of intuitive and powerful transparency mechanisms:
- Month-to-date collections
- Total failed or denied claims
- Aggregate failed or denied claims in follow-up queue
- Dollar Accounts Receivable (AR) below 30 days,
- $ AR in ( 30, 120] days
- $ AR > 120 days
- Percent Accounts Receivable (AR) below 30 days,
- % AR in ( 30, 120] days,
- % AR > 120 days
Note that national average of percent accounts receivable above 120 days hovers around 18%. Therefore, a well-performing outsourced billing service must deliver % AR > 120 days significantly below 18%. Specifically, to justify its fees, an outsourced billing service must measure its AR > 120 days anywhere around 5%.
2. Drill-down Functionality, Reporting, and Transparency
Advanced dashboard allows drill-down for more detail directly by pointing and clicking the cursor at the dashboard. At the minimum, the following features must be available:
- Operational Report shows total claims and $ amounts submitted, paid, adjusted, written off, and failed. It allows breakdown by CPT code, payer, referral, or a combination of such dimensions.
- 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 the billing service will fight for.
- Compliance Report shows the potential for post-payment audit and itemizes compliance violations.
These reports allow multiple dimensions for data presentation, by single parameter, such as, payer, CPT code, provider, or referring physician, or by more complex parameter combinations, such as pairs of payer-CPT code, provider-CPT code, or referring physician-CPT code.
3. Complexity Considerations
Note that even a small single-provider practice working with 20 CPT codes and 20 payers, has 400 (20x20) payer-CPT code pairs. Therefore, an on-line report comparing month-to-date collections between current and previous years requires powerful database query capability. Moreover, automation of such queries like “find the worst performing payer for the best performing CPT code" requires OLAP technology.
Billing Transparency is a necessary feature of a modern and accountable billing service. Billing Transparency allows the practice owner to know both the big picture and minute detail of billing process. 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 connection over the Internet. While traditional services delivered monthly paper reports, modern technology allows the delivery of continuously updated and meaningful billing performance data.
Yuval Lirov, PhD, author of “Mission Critical Systems Management" (Prentice Hall), inventor of multiple patents in artificial intelligence and computer security, and CEO of Vericle.com Billing Technologies. Vericle delivers comprehensive practice workflow engine that integrates patient scheduling, electronic medical records (EMR), billing, transcription, and compliance management. It improves billing performance and reduces audit risk. Yuval invites you to post questions on and share your knowledge of medical billing and compliance at BillingWiki.com.