As optometry’s scope of practice expands, so do the medical procedures and office visits that we perform. As such, it is critical that we have key systems in place that appropriately translate the medical services we provide into the correct current procedural terminology (CPT) codes. An internal analysis of these processes will help determine whether or not it’s best to keep your medical billing and coding processes
within the practice through current employees or to outsource those services to a third-party billing service.
Here we will discuss the key considerations in order to make this important determination for your practice.
Do you have a billing system in place in your practice?
When communicating with colleagues, I often ask if they have a system in place for medical billing. Most clinicians will describe the appropriate translation of the services they’re performing within their exam room to the appropriate diagnostic and CPT codes
. This is the first step in this process. After it is entered in the respective electronic health record (EHR), the information needs to then be submitted to the pertinent insurance plans, usually through a clearinghouse.
Explanation of benefits are usually then received from insurers to determine the coverage of services, and payments must be appropriately entered. If payment is rejected or not received by the insurer
, appropriate follow-up should be performed to determine the reason.
Often when I ask colleagues if they have a billing system in place, they say, “Yes, I have a billing person in my office.” Although this person likely demonstrates a certain level of proficiency, in terms of how they submit and receive payment, the billing system is 100% dependent on that person.
There are four crucial questions to ask that will reveal whether you have appropriate systems in place:
- Would you still be able to submit medical claims if the biller left the practice?
- Would you still be able to submit the medical claims if the biller was sick for a week?
- Would medical claims still be submitted if the biller was busy with other duties in the practice?
- In any of these situations, would insurance payments be appropriately posted?
If you answered yes to all of these questions, you have systems in place that support appropriate submission and collections from insurance companies
. If you answered no to these questions, you likely do not have a system in place, and it is all dependent on one person in the office.
How good is your current billing system?
Have you ever wondered how good your current billing system is? Have you ever wondered what the collections rate is of the medical claims submitted?
I would challenge you to go back 3 months from today and look at 20 of your medical claims. Follow them through and determine whether or not you have received payment from third-party payers. If not, find out why these claims haven’t been reimbursed. Did they never get submitted? Did the insurer reject the claim, and so it was simply written off?
Accounts receivable is a good indication of how well or how poor the billing process is in your practice. If the account receivables are high, there’s a good probability that the medical billings aren’t being submitted or collected correctly. Examine these critical components of the billing process to determine the efficacy of your medical billing process.
Is the person performing the billing being pulled to other duties in your office?
The primary biller in an office is often wearing multiple hats. Billing will pull them away from direct patient care and the opportunity to be more hands-on with patients in the office. As such, billing will oftentimes be a secondary position for that person. This becomes a difficult task for somebody to perform and, for most offices, this requires a full-time position for an individual to appropriately provide focus to the task at hand. Additionally, staying current with the rules around billing and coding is critical
Making the decision for your practice
You have a system in place in your practice that supports internal billing and coding only IF:
- You have an appropriate process in place that’s not 100% dependent on one person.
- You have a situation that accurately captures the appropriate reimbursement from medical claims.
- You have somebody that’s devoting the appropriate amount of time and effort to billing and coding.
The benefits of outsourcing are that the ICD
and CPT codes
simply need to be placed in the system and a separate entity takes care of the submissions to third-party payers and also the collections on those claims. Usually, this occurs in a remote situation in which someone, in a HIPAA compliant manner, logs into your system and scrubs the claims to make sure they are being submitted appropriately and also follows up with payments to assure the services that are billed are being reimbursed.
The benefit to outsourcing medical billing
is that it isn’t dependent on one person in your practice. Typically, the third-party billing services will have several individuals that have redundant functions in order to make sure the processes continue to occur in a timely manner. This can make significant contributions to lowering account receivables and making sure they stay low as well as appropriately making sure everything is being submitted and collected properly.
Reviewing these systems in your own practices will determine whether or not outsourcing medical billing is the best option for you.