From: "Ernie Leland" <Ernie@orchardsfamilymedicine

From: "Ernie Leland" <Ernie@orchardsfamilymedicine.com>
Sender: Practiceimprovement1@yahoogroups.com
Mailing-List: list Practiceimprovement1@yahoogroups.com; contact Practiceimprovement1-owner@yahoogroups.com
Date: Sat, 22 Jul 2006 01:17:55 -0700
Subject: RE: [Practiceimprovement1] thoughts on small and on quality & BILLING
Reply-To: Practiceimprovement1@yahoogroups.com

I know this topic was played out last week, but could not resist as I just read through 230 postings from the last two weeks.

We do our own billing and collections. Elise sees about 10 pts per day five days per week. Our office consists of a full time MA/receptionist. We are hiring an additional physician Oct. 1. I work in our office part time. I do several other things besides billing and running the office. I have been spending about a day each week at the office. I do billing, deposits, EOB’s, statements, ordering supplies, tax reporting, A/P, A/R and handling insurance companies. I usually spend an additional day once a month catching up on our lost HICFA’s and the like. We collect about $20,000 per month so the fee would be $1200 or so at 6%. In my other activities, the lowest I make is about $50 hr. so I lose money by not out sourcing it. (My time lost is about $50*5*8=$2000 per month) But I do it because it keeps me in our business and I do more than just billing and collections. I figure Elise bills at about $240 per hour and we collect about $160 allowable for that patient time. (She has non billable admin, lab, catch up time as well that I am no including in that number.)

What we do: Elise codes the note in e-MDs. E-MDs create the bills in a few clicks. I review each bill, then create a batch and electronically send it in. We (hopefully) get a check four to six weeks later. I enter the EOB into the system, and generate a statement for the remainder due and send it. Once a month I send new statements for old amounts. We have a handful that are old and the person has moved, never existed, etc. but for the most part, our patients just pay. We have more trouble with insurers and Medicaid & Medicare in particular. Medicare seems to take any i that is not dotted throw out the claim. But those also are far in between. I called on all our delinquent (90 days plus) patients in about 30 minutes the other day. I think we will write some off, but we would with a billing company too, and probably more of them. My theory goes that it is hard to tell someone you know that you are not going to pay for services. It is much easier to tell XYZ collections that you are not going to pay.

Kevin: I would love to hear how the auto-posting of EOB’s goes. I am interested in that as well. We use eMD’s and THIN for our clearinghouse, but I would switch for auto-posting without hesitation. I hate entering all the EOB’s.

To answer Matt’s query: Elise’s total time is around 40 hours. She has 28.5 hours of scheduled time slots for a total of 57 appointments available per week. She does very little business admin, just clinical admin and notes. I do business stuff in 5 days/month or 10 hours/week. We take home about $112,000 per year. (That is the last three months annualized. Our practice is going to be one year old Aug.1. So our income still fluctuates considerably.) (We have collected $153,868 so far and anticipate collecting about $170,000 our first year.)

My soapbox: I think you have to gauge individual strengths. Elise would not due well at billing, as she would not likely spend enough time on it. I do well on it with my business background and interests. SMALL BUSINESS IS ABOUT PLAYING TO YOUR STRENGTHS. If you hate accounting and money, outsource it. (Assuming that outsourcing is a financial possibility.) (And yes I do think a doctor’s office is business. J) Having said you should outsource it if it is not a strength, the doctor must understand coding and billing to ensure that they are getting paid correctly. If you outsource it, plan on reviewing EOB’s for an hour a month. Elise gets direct feedback from me. (I reminded her that medicare does not pay preventive visits today. I let her know which companies pay for an E&M and preventive on the same day. She gets harassed if she does not include the right modifiers. It all generates money for us on an ongoing basis.) So I guess she has outsourced the billing to me.

If you are selecting an employee who is going to do it make sure they are good at it, “have a knack for it”. I just visited a local doctor who wanted help getting his “money from the insurance companies.” (He is a typical office, one doc, one RN, one MA, one biller/coder, one receptionist, and, would you believe it, one marketing specialist.) He is billing $75 per RVU, which is 17% higher than the highest payer in our area. He has been open since last Oct. or Nov. and just managed to successfully submit a bill to Medicare. He does not know which insurers are paying him, (He is an allergist and performs a test that he bills at $850 and only some insurers pay for it.) He has a huge population that is Medicaid, which doesn’t pay enough to cover his first two employees little less the last three or himself. He is billing $40,000 a month, collecting $12-18,000 and if my guess is right spending $25,000 before paying himself. He doesn’t know or understand the business side, and his biller, while nice, also doesn’t understand business either. I think he is destined to go under. My point is outsource or delegate as much as you like, but understand what you are delegating. If you think you should be collecting 80% of what you are billing and you only get 60%, it is time to understand what is happening, why, and take action. Don’t get buried in the clinical and forget you are running a business.

I think Kelly has a great point, find what works well for you and do it. Some on the list due everything by themselves in a 100 sq ft room on a self-made EMR surrounded by furniture they made themselves. Some offices look like ours. Some have more employees, more outsourcing, in short, more overhead. It is about finding balance for your self.

Cheers,

Ernie

From: Practiceimprovement1@yahoogroups.com [mailto:Practiceimprovement1@yahoogroups.com] On Behalf Of David Brock DO
Sent: Monday, July 17, 2006 7:06 AM
To: Practiceimprovement1@yahoogroups.com
Subject: RE: [Practiceimprovement1] thoughts on small and on quality

Right! My thoughts almost exactly! Isn’t outsourced billing starting to head right back towards the high volume-high overhead style? That is the traditional mode of thinking (non-IMP): someone else can always do it cheaper than the doctor who should be churning pt’s through because that is what brings in revenue.

David

-----Original Message-----
From: Practiceimprovement1@yahoogroups.com [mailto:Practiceimprovement1@yahoogroups.com] On Behalf Of John Brady, MD
Sent: Sunday, July 16, 2006 11:11 AM
To: Practiceimprovement1@yahoogroups.com
Subject: RE: [Practiceimprovement1] thoughts on small and on quality

But therein lies some redundancy. If you are spending the time going over every EOB (which I do believe is necessary) and spending time answering questions from the billing company and corresponding with the billing company over questions and codes and such, you are spending time on the billing and still paying someone else to do it. That to me is very frustrating. For example, when I was getting my website done, the process was horrible. Around every corner there was another question and by the time the website was complete, I felt like I could have bought books and done the whole thing myself for a fraction of the cost. It’s the same thing with billing. If I outsourced, I would still be looking over the shoulder of whoever was doing the billing and thus spending unreimbursed time doing what I am paying them to do.

I also find doing the billing myself adds another dimension to the doctor-patient relationship. I know who has insurances that are not going through, I know who is having tough financial times, heck, I even know who has moved and hasn’t given us a forwarding address.

As for “economies of scale,” isn’t that the argument that got us on the treadmill of having to push patients through too fast in the first place. It makes complete intrinsic sense, but then why not outsource all the payroll stuff, all the other practice management stuff, all the telephone stuff, etc. After all, physicians are one of the highest paid groups of people, so almost any task can be done cheaper by someone else. The problem is that every person (entity) added increases chaos and confusion and thus increases costs and diminishes the doctor-patient relationship. That is the real reason I try and do the horrible task of billing myself.

John

-----Original Message-----
From: Practiceimprovement1@yahoogroups.com [mailto:Practiceimprovement1@yahoogroups.com] On Behalf Of Matthew Levin
Sent: Sunday, July 16, 2006 10:03 AM
To: Practiceimprovement1@yahoogroups.com
Subject: Re: [Practiceimprovement1] thoughts on small and on quality

RE Outsourcing billing, and EOBs.

I review EVERY EOB, even though I outsource.

But how much time do you want to put in to track down ONE $20 recharge, refund?

For ex, our billing company called Fri to tell us that a long-time pt had called them, saying that she now has a high deductible, and can't pay the bill from earlier completely, wants to make payments. Billing co called us for confirmation, since we hadn't done that before. We said yes. Billing company will follow up on this.

My office ass't (a 1/2 time MA), spent the rest of her morning working on issues with a pt with probable recurrent c.dif, getting a specimen processed, coordinating with hospital and pharmacy.

I'll see that pt this coming week; billing company at about equivalent for month of $5/hour will field and process call. If the reimbursements would get to equivalent of $10/hour, either decide on inhousing it with another employee, taking on the responsibility of all the infrastructure AND my time.

This is the old argument of time vs money, outsourcing at a better price to someone who can call on "economies of scale" to do the job better, vs me to keep the costs down.

I agree that the review of the EOBs is necessary, and I review each one. But the data entry I'm pleased to outsource, and the service to my pts allows my limited office staff to problem-solve the complex cases, not get caught up in the forest of lower reimbursement for the trees of higher reimbursement issues.

Just my way... others of course have other priorities.

Thanks for sharing yours.

Dr Matt Levin

Pittsburgh, PA

Solo since Dec 2004

In practice since 1988

----- Original Message -----

From: mkcl6@aol.com

To: Practiceimprovement1@yahoogroups.com

Sent: Sunday, July 16, 2006 8:56 AM

Subject: Re: [Practiceimprovement1] thoughts on small and on quality

The other thing to consider, which I think John was trying to say, is that when it is your own money, you may try harder. Also, I learn a lot about reimbursement and my practice which I didn't quite process when someone else did my billing. They would give me monthly reports, which I would read in depth, but it's different to read the eob, enter it, remember the patient and what you did, then try to figure out why they are paying for the immunization but not the exam you also did that day.

It is also a volume thing. Although it sounds like both John and Matt have enough volume to do the billing either way. I guess from a financial sense I don't. (I just started up this new practice in Jan). Still, I think I will close to new patients before I will give up the billing, for a while anyway. It is a nice administrative break, in some ways, that allows me to look at the business side of my practice and do some thinking and managing data. It sets me off looking at particular reimbursements etc... that weren't examined as closely in the old system when I shared a traditional practice. I was in the military for a fairly long time, so I was a department head by the time I got out. At any rate, this meant that I had "admin days". It kind of reminds me of that, time to sit down and look at what is happening in your "clinic", working, but not in a clinical way. Kristin

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