BILLING COMPANY STANDARDS

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1 BILLING COMPANY STANDARDS ASSESSING PRACTICE VALUE OF OUTSOURCING Cost Saving Efficiencies gained Improved collections Compliance Once a decision to out source is made the following due diligence should be completed in the process of selecting a billing service. COMPLIANCE 1. Compliance plan in place. 2. HIPAA/HITECH regulations policies, procedures & system in place. 3. Compliance with Federal, State and local laws and regulations. 4. Compliance with insurance company s policies and procedures. 5. Process for fraud & abuse investigations in place. 6. In-house audit system in place. 7. System for periodic audits by outside firm (ie every 3 years). HUMAN RESOURCES 1. Organizational chart with FTE 2. Assignment of staff to work functions 3. Benchmarks staff are accountable to for their performance 4. Use of certified coders 5. Policy and Procedures to include: o Coding o Charge entry o Data entry o Charge and log reconciliation o Charge correction o Billing third party payors o Billing secondary insurance o Claim edits o Payment posting o Payment posting bank deposit/lockbox o Payment posting interest payments o Credit balances and refunds o Claim denials o Insurance follow-up o Contractual write-offs and adjustments o Small balance adjustments Prepared by: Bette A Warn, CMPE Presented: CMGMA Spring Meeting 04/12/ P a g e

2 o Collection account transition o Budget plans o Collection agency policy o Collection agency payment posting o Documentation/reporting of collection accounts o Settlements o Bad address o Deceased patient o Non-sufficient funds o Collection letters/statement notes o Collection follow-up o Collection disputes o Telephone collection 2. Regular audits of compliance with policies and procedures using systematic audit plan. 3. Regular meetings to review policies and update as necessary. 4. Policy on having certified coders on staff and auditing their coding 5. System for staff training: i) initial orientation; and ii) ongoing for updates. 6. Hiring / background check policy. 7. Bookkeeper on staff. COMPANY (General) 1. E & O insurance in place. 2. Experience in billing for any specialty as required. 3. Policy on termination of contract. 4. System for training providers on appropriate documentation. 5. Timely review of provider documentation with appropriate feedback to provider. 6. Attendance at provider meetings to discuss feedback and any issues. 7. Timely communication of any issues or problems with client. 8. Ability to interface with medical records and IT departments at affiliated facilities and handle problems associated with these departments. 9. Ability to stay up-to-date on industry changes. 10. Electronic data interface with affiliated facility sites. 12. Toll free phone lines for patient inquiries. 13. Annual review of client fee schedule BILLING 1. Insurance companies billed electronically. 2. Insurance payments posted electronically. 3. Information transmitted between billing company and client electronically. 4. Identified account representative available for contact. Prepared by: Bette A Warn, CMPE Presented: CMGMA Spring Meeting 04/12/ P a g e

3 5. Handle all billing related and ancillary documentation to insurance companies and private-pay patients. 6. Timely deposit procedure in place (ie lock box or P.O. Box). 7. Timely submission of claims to insurance companies (ie weekly). 8. Timely statements to patients (ie monthly). 9. Coders responsible for: CPT coding; HCPCS coding; ICD-9 coding 10. Process for handing problems, such as incomplete billing information. 11. Process for handling electronic rejections. 12. Charges confirmed against daily service log PAYMENT POSTING / FOLLOW UP 1. Electronic remittance posted by whom and how often 2. Lock box transfer of payment documents 3. Process for handling returned claims and statements. 4. Payments posted by line item (not just by total amount of claim). 5. Policy and procedure for posting zero payments. 6. Policy and procedure for posting and tracking denied claims. 7. Policy and procedure for tracking and resolving rejections. 8. Policy and procedure for timely reporting on credit balances. 9. Policy and procedure for handling credit balances. 10. Policy and procedure for handling refunds. 11. Reporting on abandoned property, Escheat. 12. Policy and procedure for reviewing reports and determining bad debt, write offs. 13. Policy and procedure for determining bad debt and write offs. 14. Policy and procedure for small balances (ie kept on books or written off ). 15. Policy and procedure for matching expected payment. 16. Internal control policy for segregation of duties related to handling cash. 17. Ability to reconcile cash collection posted to bank account. 18. Policy and procedures for dealing with denials 19. Policy and procedures for dealing with appeals 20. Management of timely filing of claims and appeals DATA ENTRY 1. Transfer of demographic and documentation to billing service 1. Process for data entry. 2. Process for verifying and auditing data entry. 3. Timely processing of claim (ie no more than 1 week from receipt of data to processing of claim). 4. Process for reconciling visits to claims generated Prepared by: Bette A Warn, CMPE Presented: CMGMA Spring Meeting 04/12/ P a g e

4 REPORTS 1. Standard and customized reporting available. 2. Cost associated with customized reports 3. Aged Report by billing date, date of service, by location, and by provider. 4. Report available showing: i. Patient name; ii. insurance company; iii. charge; iv. payment; v. adjustment vi. balance. 5. Report available showing names, amounts and reasons for bad debt, write offs, and full adjustments. 6. Reports available in electronic and hard copy format. 7. Reports available real time remote 8. Days in A/R, total and by payor. 9. Net Collection Rate in total, and by payor. 10. Payor denials and reason. 11. Payor mix as % of A/R, and A/R > 90 days. 12. Average charge entry lag days (# of days between date of service and date charge was entered). 13. Average claim lag days (# of days between date charge entered and date claim produced). 14. Average payment lag days (# of days between date claim produced and date of first payment). 15. Total A/R for Insurance, Patient, Appeals, Collections, Patient payment plans. 16. Activity report by code (Top 25 codes Charges, volume, RVU, % Charges, % receipts, Receipts, by month and YTD). 17. Payor report (Charges, receipts, adjustments, A/R, % of total). 18. Monthly narrative on prior year versus current year results. 19. Internal reporting managed care exception report contracted rates versus payment. COSTS 1. Fees determined upon percent of amount collected or per chart fixed fee. 2. Policy on charges for paper claims. 3. Policy on extra cost for adding a new physician to the system. 4. Policy on costs associated with conversion process. 5. Timely conversion process. 6. Policy on handling A/R from previous billing company. 7. Additional charges for coding service COMPUTER / SOFTWARE 1. What software is used and how does it interface to practice Prepared by: Bette A Warn, CMPE Presented: CMGMA Spring Meeting 04/12/ P a g e

5 2. What ancillary features are available to the practice if using the billing service software, such as scheduling, RX, referral tracking, authorization, verification 3. Security system in place with monitored access. 4. Regularly scheduled virus checks. 5. System backed up regularly and back-ups stored off-site. 6. Process for handling yearly computer system updates for: i. CPT codes ii. HCPCS codes iii. ICD-9 codes 7. Software tracks patient demographics. 8. Capability for system to handle two primary insurances and differentiate which needs to be billed by date of service. 9. Policy on payment by client of software license. 10. Policy on payment by client for any software or hardware updates or maintenance. 11. Policy on payment by client for any hardware. 12. Use of latest version of billing software available. 13. Use of web based applications to skip trace patient s demographics 14. Use of EMR and interface to billing software COLLECTIONS 1. Separate department that handles collections. 2. Reports showing patient s name, service provider, insurance company, charges and reason for insurance rejection. 3. Collection policy/procedure for private-pay patients. 4. Process for calling patients with past-due balances. 5. Process for documenting services provided but not billable due to timeliness. 6. Process for turning over an account to a collection agency. 7. Policy on fees charged on collection agency collections. 8. Policy on legal fees related to collection issues. 9. Disclosure of collection agency company used and related fees charged. 10. Policy for Charity to patients 11. Policy for financial discounts 12. Policy for budget plan MANAGED CARE CONTRACT COMPLIANCE 1. Ability to build payer fee schedule into software for underpayment recognition 2. Reimbursement policies of payers built into Practice management software or ability of clearing house to identify at time of claim submission 3. What clearing house is used and who bears the cost 4. Analysis or reimbursement rate for contracting 5. Credentialing service full service- partial service 6. Who communicates with payer representative regarding problems with claims payment Prepared by: Bette A Warn, CMPE Presented: CMGMA Spring Meeting 04/12/ P a g e

6 7. Negotiate contract rates BILLING AGREEMENT 1. Compensation methodology 2. Timing of billing service payment 3. Term of agreement 4. Recurring or Evergreen 5. HIPAA HITECH language 6. Definition of practice records 7. Definition of billing records 8. Transfer of documents (electronic and paper) upon termination (data ownership) 9. Record retention and destruction policy 10. Audit and litigation assistance 11. Identify responsibilities of both parties Prepared by: Bette A Warn, CMPE Presented: CMGMA Spring Meeting 04/12/ P a g e

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