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Top 10 Operations Questions US Healthcare Providers Should Ask Their Potential Outsourcing Partners

The decision to outsource your medical back office processes is a daunting decision – at the least. While


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.


1. What percentage of claims do you typically bill out within 24-48 hours from receipt of the

While the gold standard is 100% for most specialties, anything over 98% is above industry benchmarks. Anything less than 95% would impact your cash flow and payment cycles.


2. What is your average clean claim rate for Clients that you have had for over 6 months?

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.


3.What percentage of the clearinghouse rejections do you typically resolve within 24 hours from rejection?

This should be 100%, with the exception of any rejects that are pending feedback from you.


 4. How often do you follow up on outstanding claims?

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.


 5. What is the percentage of claims you can commit to collecting within 90 days from the date you receive the claims from the provider?

Most outsourcing vendors would dare to make a verbal commitment on this KPI and are 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 is important to note that this KPI is a reflection of the effectiveness of the billing and the initial     collection follow up efforts.


6. What percentage of ERAs and EOBs are processed and posted within 24-48 hours of receipt?

With all top payers supporting Electronic Remittance Advice (ERA) 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.


7. What percentage of denials are typically addressed within 24 hours of receipt at the posting stage?

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.


8. What percentage of secondary claims are typically billed out within 24-48 hours of receipt at the posting stage?

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.


9. What’s the typical timeline to submit new patient statements?

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.


10. What’s your current bad debt adjustment % on average?

While the goal would be 0%, anything less than 0.5% is reasonable due to external factors that may impact recovery of certain claims.

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