Billing Services failure - One simple reason

Medical Practices outsource their billing to companies that specialize in providing such services. 

During my conversations with practices as well as billing service providers, I constantly hear about certain practices not happy with the services that they get. I also hear about billing companies complaining about how certain practices do not cooperate. In the end, it is the practice that has to bear the brunt because of inefficient billing and loss of revenue.

I know for a fact that each billing company has majority of happy and satisfied clients. Why is it then that certain practices end up not being happy with the services?

Irrespective of the software platform and vendor, let us look at the billing process. The practice selects the codes in most cases after the patient encounter. This may be a manual or an EHR based process. The billing company creates claims and submits them. If the submission is successful, the billing company follows up regarding payment and does what it has to do post payments, run reports, and manage the aging or outstanding balances.

Theoretically, all of this should run smoothly. There are certain points of communication between the billing services company and the practice. For example, there may be problems with

  • patient demographics,
  • insurance details,
  • errors in coding,
  • need for further clarity on claims by the insurance companies,
  • proof of documentation, etc.

This is usually a manual process that is established between the practice and the vendor. And, also the main stress point or cause of failure. The process may involve faxing, phone calls, or secure messaging. There should be a person assigned in the practice that understands some level of billing process so that they can effectively communicate with the vendor. It is this middle person that plays a very pivotal role in the success of outsourced billing process.

This person does not have to be an accomplished biller or an officemanager. He or she must have the basic understanding of billing process so that they can communicate with the vendor and act as a middle person to make sure there are no bottlenecks and nothing falls through the cracks. This is the most important element of success or failure within outsourced billing company.

How to say NO as a Leader?

Here are some common places where you learn how to say NO.

There are times in life and dealing with your staff when you just have to say no. Perhaps it’s a suggestion about a strategy, execution of certain tactics, product and product features, marketing, human resources … and so on.

Or perhaps it’s about a feature that you have no intention of building, resources that you can’t dedicate, or promises that you know you will not keep. But this monosyllabic word is probably the hardest one to utter. It closes all doors and destroys all possibilities. And nobody likes to be the bearer of bad news, especially when these come from your most trusted and loyal employees that are looking out for the company as well as your clients.

So how do you say no?

According to a blog I read, here’s what the blogger suggests and I agree with it.

You cannot say ‘no’ to the people you love, not often. That’s the secret. And then when you do, it has to sound like a ‘yes’. Or you have to make them say ‘no.’ You have to take time and trouble.”

Employees will believe that as long as they think in the best interest of the company as well as clients, it will be done. Things are not that simple. Sometimes you cannot do what they are suggesting.

Most companies now sell products, but also provide professional services. It is important therefore to let clients know and keep on making them aware that you offer them. Equally important is to let clients know that the product(s) are standard off the self and not ‘work for hire’.

The problem is, sales! Sales folks will often say yes to anything when asked by prospective clients of the product’s ability to solve their problems.

Other departments that deal with the NO problem.


Prospects ask if you have certain features in what you are selling. Most sales people will go down the list of features and find out if they have the features that the prospect is asking for.

Sales stars, instead, solve a problem. Before even thinking about saying No, they will try to find out the reason behind the request for that feature. Ask Why – 5 times if you have to – to get to the bottom of the request so that you can help solve a problem and therefore turning a No into a Yes.

Customer Support

It is very similar to what I outlined above for sales. But here you have a slight advantage. The client is already using your products. They may be asking for a feature request but may not be able to articulate the reason behind that request. So, help them (and yourselves) solve the problem instead of focusing on features. If your company is offering professional services, you have an added advantage.

Back to Company Leaders

Dig in, dive in, engage employees, and understand the root cause and reasons. Instead of a flat NO, put yourselves in their shoes, and identify the issues that need to be solved. Perhaps you have a better solution, or workaround that fit within your boundaries and framework.

Copying from the Blog I was referring to (Click here to read that blog):

  • Things you CAN do + Stuff you SHOULD be doing: If you CAN do something and that’s the direction your customer base really believes you should be working on it, that’s a good reason to pump the gas on this one. These are under the radar issues that would crop up as you scale. It isn’t a customer problem currently, but it will be eventually.
  • Things you CAN do + Stuff customers WANT you to do: The Route to Professional Services. These aren’t things in your real road-map, but could offer as Professional Services. Take this route ONLY if you have the bandwidth and resources. Otherwise be nice, but say No.
  • Things your customers WANT + Stuff you really SHOULD be doing:  Road-maps to Nevada. Your current customers want it, and that is what your industry dictates you should be doing. Therefore grow, hire and provide the service or get ready with the best apology speech in the history of mankind.
  • Things customers WANT + you SHOULD + CAN do : The Commission’s Overlap of Possibility. This is your absolute high priority items. Never ever ever say NO here, even if it means shaving off a few dollars.


MACRA, Physician Reimbursement, and Moving beyond MIPS

Dr. Gail R. Wilensky, Ph.D has just wrote a thought provoking perspective in the New England Journal of Medicine. ("Will MACRA Improve Physician Reimbursement?" April 5, 2018)

Tracking the journey from Resource based relative value scale (RBRVS) and Sustainable growth rate formula (SGR) which was not really a value based system, to current MIPS portion of MACRA (Medicare Access and CHIP Reauthorization Act); it becomes clearly evident that it is still work in progress. 

MedPAC March 2018 Report to Congress - Monkey Wrench

While agreeing with the initial goal of MIPS, MedPAC has thrown a monkey wrench, claiming that MIPS is a burden along with the claim that it's goal will not be accomplished.

MedPAC shares Congress’ goal, expressed in MIPS, of having a value component for clinician services in
traditional Medicare that promotes high-quality care. However, the Commission believes that MIPS will not
fulfill this goal and therefore should be eliminated.
— MedPAC March 2018 Report

They are making two recommendations:

  1. Eliminate MIPS as it is today.
  2. Establish a new 'Voluntary' value program in fee-for-service.

As Dr. Wilensky points out, 'Under the MedPAC proposal, physicians would have 2% of their fee-for-service payments withheld. To get the withheld money back, physicians would have to join an A-APM or be part of a (real or virtual) group that is evaluated on population-level performance measures such as mortality and readmission rates, potentially preventable admissions, and patient experience. MedPAC also proposes that the measures be based on claims, which would mean that the burden would be on CMS rather than clinicians to provide the relevant data. Clinicians who do not participate would lose the 2% that was withheld.'

Even if we agree with MedPAC's assessment that MIPS has flaws, I'm not sure if anyone has the answer. MedPAC has an alternative proposal, but dumping MIPS altogether is probably not wise, until CMS tests and tries the MedPAC proposal. Dr. Wilensky proposes that CMS should test it under its Innovation Center (CMMI).

In either case, we are certainly making progress. This is such a huge issue that we must test and try various models. There is no silver bullet. While Practicing Physicians will encounter a bumpy road, we must all pitch in to make our views known and heard.



Procrastination - Just One thing to do

I have suffered from Procrastination all my life. I guess who hasn't - to some extent, some more than others. 

I am 55 now and I don't say I have fully overcome it, I don't think I ever will, but I have to a large extent controlled it.

I recognized this is a huge issue when things started suffering. Work got delayed both at home and office. I kept pushing things off to the point of no return. I then started reading about it, seeking self-help books and articles. When I read them, I resolved to get better, and I procrastinated on those resolutions. 

There was a lot of theory. Here is what one article said:

Follow these steps to deal with and control procrastination:

Step 1: Recognize That You're Procrastinating. If you're honest with yourself, you probably know when you're procrastinating. ...

Step 2: Work Out WHY You're Procrastinating. This can depend on both you and the task. ...

Step 3: Adopt Anti-Procrastination Strategies.

Here's another article: If you're looking for effective ways to beat procrastination and finish your tasks timely, these 8 tips are for you.

  1. Eliminate distractions.
  2. Use your strongest sensation to memorise things.
  3. Set yourself deadlines. ...
  4. Work when you feel most alert and efficient.
  5. Don't stress too much.
  6. Eat healthy & exercise.

...and on and on...

My wife is the exact opposite. She is always on top and never procrastinates, and that's not an exaggeration. I observed her. I noticed and started implementing just one simple thing.

Just Do It!

When something comes to top of mind that needs/should be done, just do it right now. I initially felt - I'll do it as soon as... or 'I'll do it later'. We know what happens. Then, I realized if I stop what I am doing, and just get that thing done, it is not going to disrupt anything at all, because most of the time, what I am in the middle of, is never that urgent.

That's all - no long theories, no steps, Just Do It.

Best Way to Evaluate any Product - Ask - "And Then What Happens?"

Seth Godin's blog below got me thinking. This is how we should evaluate software and technology products.

A simple dialog can turn opinions into plans (or perhaps, into less tightly held opinions).

We ask, "and then what happens?"

Flesh it out. Tell us step by step. The more detail the better.

No miracles allowed. And it helps if each step is a step that's worked before, somewhere and sometime else. The other question that helps with this is, "has that step ever worked before?"

We don't have a shortage of loud and strongly held points of view about business, culture, or technology. But it may be that finding the time to draw a map helps us get to where we want to go (or to realize that we need a new map). 

What does all this have to do with Product/Software Evaluation?

When doctors buy EMR software, majority of them make the mistake of doing an improper evaluation and testing before buying. This leads to dissatisfaction and practice inefficiencies. Medical clinics have a lot of moving parts and workflows. Doctors will evaluate from the clinical perspective. Office managers and billing staff evaluate the systems from their own workflow point of view.

Where it gets complicated is that they focus on inefficiencies and dissatisfaction with their previous software. They assume that other parts of the system work fine. The evaluation needs to happen as if you are buying a system for the first time.

Every step of the process must be evaluated independently.

Do your homework.

This requires a lot of homework. Start by documenting every step of the process. This is more difficult than it sounds, because you have been doing things for a long time and you take things for granted. You don't do not feel the necessity to document simple steps. Once all the steps and workflow have been documented, this is where you need to ask the vendor, 'then what happens?' Keep on asking this question until you know the exact steps that you have to take in that software to do your job - everyone's job.

There is another side benefit of doing this. It will prevent future finger-pointing. In majority of the cases many unspoken things lead to discontent. How many times have I heard, "I thought you said...", Or, ... "You never told me this..."

Do yourself a favor, and keep on asking "and then what happens?". Spend as much time as necessary with the vendor evaluating the product.