Billing isn’t discussed much in medical school but its pretty important for a physician. Billing is how you get paid. Like any business or contractor, if you’ve not on top of your invoicing, you’re probably losing money. A 2019 study from Ontario concluded that physicians on average we’re missing 7% of their public health insurance claims. That equals almost $25,000 for the average Canadian physician. For specialist physicians, this amount can be over $50,000 per year. But most physicians don’t put that much thought into their billing provider. When new physicians start, most just ask their colleagues who does the billing and then use that provider. In this post, we’re going to run through what physicians should look for in their biller and red flags to be concerned about. Having a good biller vs. a bad biller can mean a difference of hundreds of thousands and potential over +$1,000,000 in lifetime earnings. It’s your income, and it’s well worth putting a little thought into who manages it for you.
What to look for in a biller
It can be quite difficult for a physician to assess the quality of their biller. We’ve created a list of things to look for and consider when choosing a biller.
Transparency
If you can’t see, you don’t know. A good biller should provide you with clear transparency to what’s happening with your billings. This includes what get billed, what gets rejected, what follow-up is being done, and what claims ultimately go underpaid or unpaid. The reality is that some of your claims will be rejected. This can be because of submission errors, a requirement for further details, or errors on behalf of the insurance payer (yes they make errors). A good biller will follow-up to resolve issues and ensure each claims get paid. If you can see what’s happening, you can make sure your claims are being followed-up correctly.
We regularly do audits for clients coming from other billers and we find 2%-10% of claims are unnecessarily lost. We’ve seen example where rejected claims just aren’t followed up on or even where claims just didn’t get submitted. Most of the physicians had no idea the errors were occurring.
Some companies with technology provide on demand information about all your claims. If your biller doesn’t have good technology, at a minimum you should get a monthly report detailing what was submitted, what was paid, and what was rejected. And this report should be reconciled to your statements of assessment (ie you shouldn’t have to reconcile your own claims). If your biller, can’t do this, strongly consider switching. Transparency is the first step to knowing what’s going on.
Competence
Competence is hard to judge because … well the billing agent is supposed to be the expert. So how do you know if your biller doesn’t really know their stuff? Asking questions is a great start. If you have a rejected or unpaid claim, ask why. A biller should be able to clearly explain why a claim was treated in a certain way and be able to reference the relevant rules in the insurance schedule. If they can’t do that, its a big flag. “Sometimes they just don’t pay those” is not a good reason. Incompetent billing is where most physician lose most of their money. This can be incorrect code submission, failure to submit codes, and failure to follow-up on rejected codes. If you see any of these things happening, start asking questions.
Optimizations
Optimized claims is a level up on being having competent biller. Insurance schedules are complex and often there are multiple ways to bill the same service. For example, a complex consult could be billed under a complex consult code or as a consult with a complex time modifier. Both are acceptable ways to submit, but depending on the length of the consult, 1 code combination is correct and will pay more than the other. Loses to un-optimized claims tend to be smaller than competency issue errors, but they can still equal 1%-2% of your billings and hundreds of thousands of dollars over your career. A good biller should be able to explain how they can optimize your billings. Some technology based billers will show you the optimization when the claims are submitted.
Technology
Technology can make everything easier about your billing – secure document submission, better transparency, clear reports, etc.. Technology is easy to judge wants you use it. If your choosing a new biller, ask for a demo of the technology. Other physicians who use the technology are also a good source of advice on what to expect. Good technology will also offer convenient reports for accountants for end of year tax time.
Level of Service
Billing companies provide a wide variations in level of service. Some of this is personal preference. Some physicians want everything taken care of, other physicians prefer to manage more of the process themselves. Here are the different service levels consider:
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- Claim Submission – This is process of sending your claims to the payer. Most provincial health insurance plans do not allow an individual physician to submit claims for payment without using some type of accredited billing submitter.
- Coding and Transcription – Don’t want to enter your claims? Many billers will offer coding and transcription services based on submitted day sheets.
- Claim Follow-up – We’ve said it before – claims get rejected. Some billers offer claim follow-up and rejection management. This includes finding out the issue with the claim, gather any additional information and documentation and resubmitting the claim. To us, this is the most important value a biller can provide. Good claim follow-up increases a physicians earnings and it can be very time consuming for a physician to do personally.
- Level of Support – This is all about responsiveness. If you ask a question, do you get a prompt response? Can you call or email? A good level of support makes you confident you can get answers and resolve issues quickly. A bad level of support leaves you hanging.
- Type of Claims Handled – At a minimum, all billers will submit to provincial health insurance plans. These submissions usually cover Out-of-Province (OOP) claims. For a typical physician, this usually covers 90%-95% of all billings. Many billers will cover federal health insurance plans (RCMP, military, federal inmates, refugees) and provincial WCB plans. Some billers will submit or manage private claims and private insurance. Generally, the more payers covered, the better the service. Some physicians don’t have many non-provincial claims and so don’t think they need to worry about billing coverage. But even if you only have a few claims a year, you can be losing several thousand dollars. And managing your own claims for federal health insurance or private claims is usually an unproductive and unpleasant use of your time.
Types of billers
There are many different billing companies available and the type of biller your choose is going to be partly personal preference. To understand the options, here’s are the types you’ll encounter:
Paper based billers. These billers are usually small operations of 1-10 people who manage billings the old way (ie via paper and fax). They usually offer transcription and follow-up on claims, but offer limited technology or transparency. There are very wide variations in levels of quality and support.
Self serve, no follow-up. These billers are usually more technology platforms than billers. They allow you to submit claims on their platform, but tracking claims and follow-up is left to the physician. An example of this type of service is Clinic-Aid.
Self serve with follow-up. These billers provide a technology platform to submit claims, but they also provide follow-up on rejected or underpaid claims. This allows physicians to know exactly how the claim was submitted but saves them the pain and time of managing follow-up. Billing companies with this type of service include Statgo, Dr. Bill and MD Billing.
Full serve with follow-up. These billers code and transcribe your claims, provide follow-up on claims, and provide technology to view claims, track rejections and securely submit documents. Billing companies with this type of service include Statgo and MD Billing.
EMR based systems. Some EMR systems offer billing modules that allow clinics to submit claims. There are essentially self-serve, no follow-up providers but they are a part of the clinic’s EMR. We have not been impressed by these solutions. These modules are usually an add-on to the software product and not a core focus of the EMR provider. As such, they tend not to function that well or provide good transparency to the billings. We once audited a clinic’s billings and found a whole day of billings unsubmitted because there had been a connection error at time of submission. The software confidently told the operator not to touch the claims as they were awaiting assessment from the insurance provider. The claims were stale dated and lost.
Conclusion
Billing matters and having the right biller will save you hundred’s of thousands of dollars, maybe even $1,000,000 in lost billings over your career. Take the time to research and select your billing company. You’ll be happy you did.
Can we recommend anyone? Well, we’re glad you asked. There are many different billing companies, some good, some bad, but we can recommend the billing company run by the authors of this post. Statgo was started by two physicians who were frustrated by the lack of good billing options. We focus on transparency, complete follow-up, and prompt processing. We make it easy for you to see the whole process and be confident your billing is being done correctly. We’re sure there are other great billing companies out there, but we can guarantee you’ll have all the concerns above addressed to satisfaction with Statgo. You can learn more about us at statgo.ca or contact us at support@statgo.ca.