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The cost of non-integrated services

Updated: Apr 7, 2020

Practices who switch to a medical biller with integrated services often see increases in revenue. Having all of your revenue cycle management in one place increases productivity, simplifies communication, and takes the headache out of investigating and solving billing problems.


When I meet practice administrators I’m often asked if my firm offers credentialing and contracting services. After affirming that we do I’m usually greeted with a reply such as “Great! Our medical biller doesn’t want to do it and no one at the practice likes credentialing either.” When we land a new revenue cycle management account, we advise them of our credentialing and contracting services and the practice administrator may say something like “we had that done a few years back and we don’t need those services” or “we’ve got a credentialing and contracting vendor and we don’t think they do very much.”


When I hear any response that resembles those above, I know the practice has probably lost out on 5% to 20% of practice revenue each year. Here are a couple of cringe worthy real life examples when a practice doesn’t have an integrated revenue cycle management service provider who manages their medical billing and credentialing and contracting.


T H E B L A M E G A M E

A few years ago I was doing some data analysis work for a large practice who outsourced their medical billing to an overseas firm, and they had hired a separate company to do their credentialing and contracting. While analyzing their revenue I noticed evaluation and management and x-ray services were not receiving reimbursement in accordance with their carrier contract. I immediately brought this to the practice owners’ attention who in-turn conducted several meetings with his vendors and after a couple of months, each vendor was effectively blaming the other for the reimbursement problems.


Apparently, his medical billing firm represented the issue was caused by the credentialing firm and the credentialing firm said they’ve verified with the payer that the providers are credentialed and it was purely a billing issue. Bottom line, the practice wasn’t getting paid and the owner couldn’t rely on his disconnected vendors to solve the problem, so he asked me to help.


"Bottom line, the practice wasn’t getting paid and the owner couldn’t rely on his disconnected vendors to solve the problem, so he asked me to help."

Since I had insights about the practice’s revenue, I knew the payer was reimbursing at the in-network rate for all other services which led me to believe the issue wasn’t related to billing or credentialing. While it doesn’t happen often in very rare occasions a contract loaded in the payer’s system will become corrupt and won’t calculate correctly. After a couple of days emailing examples to the payer, the payer conceded that the contract wasn’t configured correctly in their claim payment system which was causing a pervasive payment error.


After fixing the root cause it took the payer about 3 weeks for the carrier to re-process the claims correctly. Afterwards, I decided to email the U.S. based person working for the overseas medical billing firm and asked why they felt the issue was related to credentialing. He couldn’t provide an answer, so he pulled together a conference call with 6 other international employees and they explained that when a procedure code is billed correctly, and it doesn’t get paid then they ‘know’ it’s a credentialing problem. Their protocol is to call the payer and get a reference number and document the practice management system indicating it’s a credentialing problem as the codes were billed correctly. In other words, we’ll place documentation in the practice management system so our client will believe we are truly putting up the good fight. I couldn’t help but think of the saber-rattling analogy where two swordsmen bang their sabers creating lots of noise, but no one has any intention of making a lethal blow.


A K N O W N P R O B L E M

After on boarding a new client who had concerns about their previous medical billing firm, we started to notice other issues the practice didn’t know about. We observed several claims were written off in full for Medicare, as well as with another large commercial payer. We also became aware that certain plans only paid the primary surgeon or assistant surgeon claim but not both. We began by investigating the claim notes, credentialing information and other artifacts to understand the full write-offs and other claims where the practice was losing revenue or not billing for services or equipment.

"We began by investigating the claim notes, credentialing information and other artifacts to understand the full write-offs and other claims where the practice was losing revenue or not billing for services or equipment."

Our new client had also outsourced their medical billing and credentialing to two separate firms. The medical billing vendor would describe within the practice management system that the claim denial was a credentialing issue and consistently stated “This is a known problem and the practice was aware of it.” We also noticed the credentialing firm would submit credentialing paperwork or do an online enrollment but never seemed to follow-up to verify whether the credentialing or contracting was completed successfully. Lastly, we discovered the practice had an approved 855-S application on file with Medicare’s National Supplier Clearinghouse but the practice wasn’t billing for any durable medical equipment.


By offering integrated services we were able to identify and resolve seven major reimbursement problems. The practice is on track to have a 20% annual revenue improvement.


I N C O N C L U S I O N . . .

What is clearly troubling in both of these cases is the non-integrated parties supporting these practices (i) weren’t communicating directly with the practice, (ii) neither vendor seemed to take ownership and (iii) did not have full visibility of which insurance carriers the practice was contracted with to ensure it was billing for all services and equipment. The previous vendors were passive, uncommitted and unaware of the practice’s operations.


At OCMS, we are an integrated revenue cycle management company where we seek to understand your practice and we won’t quit until the job is done.

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