The decision to outsource your Medical back office processes is a daunting decision – at the least. While the right decision could lead to numerous tangible and intangible benefits, an incorrect one may significantly impact the future existence of your Practice. Following is a list of top 10 questions that would help you determine the Operations capability of your Potential Outsourcing Partner.
While this varies by specialty, for most GPs and specialty providers the Gold standard would be to get to over 98%. It’s important to note that only a select list of Outsourcing vendors out there have the process and technological capability to measure and manage this KPI.
This should be 100% with the exception of any rejects that are pending feedback from you.
Most Outsourcing vendors would throw out responses such as 21 days, 30 days etc. However, smart follow up strategies involve processes supported by technologically enabled workflows that support follow up strategies customized by Payer. For example, while calling on an outstanding Medicare claim at 21 days would make sense, a Worker’s comp claim may require a call within 4-5 day from billing to confirm receipt and another call in 3-4 weeks if the claim is outstanding given the usually paper based processing and tighter filing deadlines of such Payers.
Most Outsourcing vendors would dare to make a verbal commitment on this KPI and is highly unlikely to make it a contractual commitment. While the expectation would differ by specialty, for most common specialties, > 95% would be the Gold standard while anything 95 – 98% is acceptable. Anything less would impact your cash flow and increases the risk of bad debt due to missing timely filing and/or appeals deadlines. It’s important to note that this KPI is a reflection of the effectiveness of the billing and the initial collection follow up efforts.
With all top Payers supporting Electronic Remittance Advice notices, top Outsourcing Providers are now able to process over 98% of their Insurance Payments and Denials within 24 – 48 hours. The only exception would be transactions that are pending bank reconciliation or any refunds or recoupment transactions that may require a check and balance.
This should be 100% without any exception. It is important to note that these claims are already 3-4 weeks delayed vs. the Payment cycle of a clean claim and any further delays in resolution adds to this delay. In addition, it also impacts cash flow, delays secondary billing and significantly increases the risk of not collecting any residual Patient balances.
While most top Outsourcing vendors would capitalize on electronic secondary billing when available, a higher % of Payers still require Paper submission of the Secondary claims. A good expectation would be to manage towards ensure filing of >98% of the secondary claims within 24-48 hours from receipt for paper based and 100% for electronic.
Most Outsourcing Companies would bill out Patient claims on a monthly basis. While this used to be the accepted norm, top Outsourcing vendors are recovering more Patient responsibility by submitting Patient statements within 24 hours following the posting of the Insurance Payment or denial. This requires a process and Billing System that can support daily submission of Patient balances.
While the goal would be 0%, anything less than 0.5% is reasonable due to external factors that may impact recovery of certain claims.