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Playing the game, fighting the fight: professional billing organizations specialize in behavioral health, addiction treatment claims.

The leaders of behavioral health organizations are, by and large, steady, reasonable, and patient people. So, it is comparatively rare to find a "hot-button" issue that worries, bothers, or angers them as the issue of billing and claims processes with private insurers does.

On "good" days, executives will describe the billing and claims process in terms of the revenue cycle, explaining that their teams have reduced accounts receivable (A/R) days, improved cash flows, and enabled clinical staffers to focus on their essential work. On "OK" days," they might explain it as a game that must be played, a high-stakes debate in which the opponent is always chipping away at your core argument--and your reimbursement. And on "bad" days, they see it as a lopsided battle against a mercenary enemy.

Finding people with the knowledge and staying power to play the game daily and "fight the fight" when needed isn't easy, but it is essential to the success of any mental health or addiction treatment organization. And, say experts, it's not enough to have someone with a talent for "medical" billing: you've got to find, and then keep, people who master the more specialized work of billing and claims in 1 the field of behavioral healthcare.

For organizations struggling to do that, there is an alternative: a billing service. For a fee, either a fixed or volume-based percentage of paid claims, these services promise to play the game better than an in-house team and, when needed, "take the fight to the enemy."

Us versus them

I found that these organizations, and particularly their leaders, have a certain feisty intensity that an executive or board member might welcome on really tough days. One such leader is Melissa Zachariasz, President of MedPro Billing (Tamarac, Fla.) who until 17 years ago, was an experienced medical biller for a large physician group. Her passion for the business comes from deep within.

She says she founded MedPro and got into behavioral health billing "after my father died from alcoholism when he couldn't get the treatment he needed. Back then, [the payer] wouldn't precertify a patient for treatment unless they were jumping off a bridge, and sometimes not even then." She continues, "When you would finally get it precertified, they would do anything, find any reason, to deny the claim."

When her fledgling business "did well" working with one facility, another--faced with the prospect of closing its doors--sought help. Then others, and more after that. "I really never marketed the business until the last five years," says Zachariasz, who is seen as something of a pioneer in. development of this specialty area of billing.

Today, Med Pro Billing and its employees are housed in a 10,000 square foot office, an office that features a distinctly robust design. Zachariasz says, "We were just joking that if Hurricane Isaac came our way, we'd all seek shelter at work--we've got a generator, back-up power, the Works."

Despite iviedPro's increasingly sophisticated surroundings, Zachariasz says that the business itself is quite simple: "What it is is fighting the fight, because insurance companies do not want to pay claims." Later in our discussion, she put it more bluntly: "Their job is to keep the money. My job is to get the money."

The goal: "clean" claims

The package of capabilities offered by behavioral health billing companies, which include not only MedPro, but newer competitors including Medivance (Sunrise, Fla.) and Professional Resource Recovery Solutions (PRRS, Sunrise, Fla.) include billing and collections, behavioral health benefit verifications, and utilization review management.

Medivance's president, Neisha Zaffuto, also learned billing in the field of behavioral healthcare before becoming involved with the launch of Medivance in 2007. That company's initial funding came from Zaffuto's mother. And, while its original headquarters were in a two-bedroom apartment, the business has since grown into an 8,000 square foot facility housing some 60 employees.

"The key to a successful billing relationship is having the ability to process the claims 'clean; You've got to have the relationships at the customer facility to ensure that you're getting good data in, so you can get good claims out," explains William McCormick, Medivance's CEO. "The challenge of having to fight the insurance companies, of knowing the nuances of the industry, is what the billers and collectors enjoy most," he explains, adding that after clean claims are submitted, "it's all about becoming the facility's 'advocate' for payment."

He asserts that "treatment services really want to focus on the business of care. They don't have the billing knowledge that it takes to really maximize their reimbursements. They don't have people who are able to concentrate on that, eight hours a day. We free them to be the clinical advocates, and we are their financial advocates."

Starting the conversation

What, I asked, are the problems and complaints that would-be customers face? How does the conversation begin?

According to Scott Delmarr, CEO of PRRS, service conversations usually begin when one organization hears that another is getting a higher level of reimbursement for a particular code or treatment. "Typically, an owner or an executive brings in the results of their billing group and says, 'What's the UCR (usual, customary, and reasonable fee) that you are getting for this procedure?' When we show them and when they see a difference, they think, 'maybe we should try this."

Delmarr asserts that in-house billing staffs often face common concerns and problems:

1) They are limited by the knowledge and management style of the billing and collections manager.

2) Aging receivables get too little attention Staff members don't have the experience needed to work aging claims properly, while overtaxed managers often fail to track and manage the level of call frequency needed for optimum results.

3) They are vulnerable to disruption due to the turnover of key staff members.

4) They often lack the know-how, processes, and data needed to ensure that reimbursements received are the maximum available.

Medivance's Zaffuto says that would-be customers that do billing in-house have common questions: 'What's the turn-around time for reimbursements? 'What can you do for my cash flow?' and 'Can you get me paid on time?" McCormick adds that "facilities that try to do billing on their own have such a slow turnaround time on reimbursements that it hurts their entire financial structure." He explains that A/Rs "past 95 days" are not uncommon for in-house billing teams, and states that "a billing service that's focused on reimbursement can often get that down to under 61 days."

For organizations that are already under contract with a third-party billing organization, McCormick says that "transparency issues" are often the problem--customers don't get enough information about the status of claims to feel comfortable that the process is proceeding smoothly. To overcome this concern, Medivance developed a dashboard tool that "shows the actual claim flow that goes from census to transmitting, right down to the actual collection process for the reimbursements." (See "Tools that can help") This, he says, offers the kind of transparency that the industry has wanted for a long time."

Value-added services

When the provider receives a check, it can be easy to think that a claim is closed and the jobs of billers and collectors are done. But billing services maintain that the job may just be beginning. They point to the importance of additional, value-added services:

Reimbursement auditing. EOB and paid-claims information may be audited by a billing service team to determine whether the reimbursement levels paid reflect the available maximums under the patient's policy. If past claims data or formulae show that they do not, further claims action may be taken until the maximum benefit is obtained.

Out-of-network claims management. Despite the advent of parity, providers face continued challenges with out-of-network claims, particularly for addiction treatment. According to Zachariasz, resolving these claims may require working with insurer representatives from two or more states to detail problems and demand solutions. Sometimes, even manual claims processing is required. But such claims--which might well constitute a write-off for those who lack the ability to fight them through--do ultimately get paid. "I spend a lot of my time on problems like that," she says.

Utilization review. Because of their experience with multiple providers and insurers, billing services say that that they can help providers obtain approvals for additional levels of care more effectively than in-house staff or clinicians alone. It's all a matter of practice, they say: a combination of knowing the criteria for care (i.e., ASAM or Milliman criteria for addiction treatment), asking patients the questions known to be required by the different insurers, knowing how to build the case for treatment, and submitting the replies in a format that experience shows that the insurer requires. One more thing, too: all such calls are recorded.

Patient relations and collections. Experts also agree that it is essential to pursue payment from patients whose plans pay reimbursements--often those for out of network services--directly to them, not to providers. In such situations, third-party billing organizations must act as collection" agencies--contacting patients to remind them to remit the treatment reimbursements received to the providers who delivered treatment. In the past six months, McCormick reports that Medivance has collected over $1 million in such payments from patients for remittance to its provider customers.

Provider negotiations. MedPro's Zachariasz says some providers may be unaware that third-party plan administrators are repricing the benefits from the major insurers" and using them as the basis for negotiating direct, across-the-board discount contracts with individual providers. By networking with MedPro's provider customers, she said she was able to negotiate with insurers to accept a far smaller discount for providers who billed through her organization.

RELATED ARTICLE: Steps in the billing process

While billing services focus on billing and revenue collection, the information that they need to succeed is found throughout the process of care.

1. Prior to admission, patient coverage is verified. This may be done using forms provided by the billing service. For example, MedPro offers an electronic forms management and submittal system that its customers can use to complete patient demographic, insurance, and other pre-admission forms, with data uploaded automatically. When verifying coverage, billing services say that it is wise to verify the "maximum" benefit limits, since these sometimes differ from the "allowable" levels that insurers typically pay.

2. After admission, providers must complete required screenings, evaluations, and treatment recommendations. These results are then used by the billing service's Utilization Review team to make the case for the highest indicated level of treatment for the provider's patient.

3. Once treatment begins, census and treatment information is transmitted regularly from the provider to the billing service--either electronically or via paper/fax documents. The data is then uploaded or keyed in by billing service staff members.

4. Patient and treatment data are developed into electronic claims, which are then tested to identify and fix errors prior to submittal. Electronic claims submittal follows.

5. After claims submittal, claims are placed on an aging report where their status is tracked, by insurer. Denied claims are flagged immediately so that problems can be addressed or additional information provided as needed. Alternatively, denied claims may move into the appeals process.

6. Upon provider receipt of reimbursement, the provider organization sends/transmits details of the received reimbursement checks and accompanying explanations of benefits (EOB) information to the billing service, whose fee is usually based on a percentage of the net reimbursements to the provider.

RELATED ARTICLE: Billing services: Questions to ask

* What services are included?

* Whose forms-yours or mine?

* How much staff support do you require?

* Are you training my billing staff?

* What about customer service? Who's my lead representative? Is there a single point of contact or am I going to get a can center?

* Key performance indicators on billings:

* How long-from receipt of billing materials-does it take you to electronically submit a claim?

* How will I know about the progress of claims-at 30-60-90 or more than 90 days out?

* What is the rate of claims denials?

* How long does it take to identify a denied claim? To respond to it?

* What is the process that you use to escalate unresolved claims?

Source: Michael Lardiere. VP Health Information Technology and Strategic Development, The National Council

RELATED ARTICLE: Tools that can help

Billing companies are offering new tools to make the billing process more transparent and to help their provider customers deliver and document better clinical care.

One is Medivance's "Facility InfoDash" (Figure 1) which offers a customer facility a view of each month's ongoing claims and reimbursement activity in real time. A "Clean claims" view shows claim submittal activity by total dollars, by total number of transmitted claims, by amount accepted/rejected per type of service provided, and by amount per carrier. A second view shows details of reimbursements.



Another is MedPro's FLEX EMR--a complete electronic records system (Figure 2) that evolved out of MedPro's electronic forms and data submission system. MedPro President Melissa Zachariasz envisioned this product when she heard customers complain that EHRs could cost upwards of $100,000. "We looked at what it would take to add an EHR to the data submission system and make it affordable," she explained. The system can be purchased and customized for $20-25,000.

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Title Annotation:IT VENDOR SURVEY
Author:Grantham, Dennis
Publication:Behavioral Healthcare
Geographic Code:1USA
Date:Sep 1, 2012
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