Selecting the right billing system

By Peggy L. Pugh, RN, MLT, CPC

Does your billing system work for you or against you? Do you need a degree in computers to choose the right billing system for your practice? No! You don’t have to spend four years studying computer science in addition to medical school to determine which billing system will best suit your needs. There are, though, a number of factors to consider when deciding to purchase a new or upgraded software package to handle your billing needs, and every physician should take the time to do their homework when making this crucial decision — after all, the billing system’s capabilities are the framework for bringing a healthy cash flow into the practice.

Some important initial questions you should ask of any potential vendor of billing software and hardware include:

How long has Company XYZ been in business? What is the history of the company?

How long has the particular software package you’re interested in beenon the market? How many and what types of practices use their software? Are client references available for you to call? Are ‘demo disks’ of the software available?

What is the availability and accessibility of system ‘set-up,’ training and support, as well as the approximate cost of these essential items?

Does the company have the capability to import data from your previous billing system if necessary, what is the cost for this service, and have they been successful with this?

What are the hardware and networking requirements recommended by the software vendor for optimum efficiency?

What is the cost of their ‘basic’ system and what is ‘included’? What additionalproducts are available at an extra charge to enhance the basic software package?

Contrary to popular belief, the cost of a billing management software generally has no direct correlation with the capabilities or customer satisfaction ratings of the software vendor! Medical billing/office management software packages can range in price from under $2,000 to in excess of $25,000, depending on the bells and whistles many of the software companies offer in addition to their basic packages. Most billing software packages on the market today are completely functional when utilized by appropriately educated personnel, however, keep these important ideas in mind as you shop for a software package for your medical practice.

Not many physician offices today still depend solely on patient ledger cards and a daily log sheet — the benefits of a good computerized billing system far outweigh the time consuming, duplicative efforts required by the paper systems of the past. Today’s medical offices work with systems that allow the physician’s practice features such as computerized appointment scheduling, electronic chart documentation, integrated test result reporting, electronic claims billing, electronic payment reconciliation, complete accounts receivable tracking, and internal collection modules, all of which allow the efficiency, accountability and oversight that could never have been possible with a paper process. For optimum results from any computerized system, though, be sure to allow adequate time for staff training and retraining, and build the appropriate framework for monitoring of system compliance by the administrative staff.

Rapid, appropriate reimbursement is dependent on accurate patient demographics and appropriate charge data entry. A user-friendly screen for these key functions is vital to your practice, as this is where proper reimbursement begins. Many software companies will provide the physician and staff with training sessions to assist in learning the capabilities of the billing system. It should be noted as well, that any system is only as good as its’ operators and their knowledge of the systems’ capabilities — if you are not aware of all of the possible options your billing system affords you, then you may not be using the system to its’ fullest potential. In the charge entry area, most software systems allow for easy demographic entry, creation of additional patient information tracking classes to be assigned by the practice, which will allow for specific reporting as the client needs, custom formatting and printing of superbills to allow the physician to record services rendered and afford more organized charge entry by the staff, customizable appointment schedulers to integrate with the billing system, and the auditing tools to provide assurance that all services are recorded and billed.

Other aids for data entry include code libraries that integrate with CPT and ICD-9 CM on CD-ROM or disk to save time and increase accuracy when selecting codes for services rendered, and the ability to set up multiple “code sets” in order to bill the appropriate insurance carrier with the correct, carrier specific procedure code. Some allow the ability to track procedure codes involving “global surgery” rules, as well as monitoring the total number of visits allowed for a given service authorization. Auditing tools may include reporting formats for printing daily logs of charge and payment activity, staff and practice productivity, claims submission listings, and pre-collection aging of accounts receivable reports for management review, among others.

Features in the patient demographic files vary, but it is beneficial if the software is able to archive old patient and insurance information and policy effective dates, and also a must have is a “billing notes” feature involving minimal keystrokes, to maintain an easy to use history of a patients’ account for resubmissions according to responsible payor, for reviewing charge and payment activity and for determining financial responsibility.

Payment entry is made more efficient with software that includes electronic payment reconciliation capabilities, allowing the practice, for example, to post a 50 page Medicare Explanation of Benefits in a matter of minutes versus the hours it could take with manual payment posting and reconciliation. Most systems are able to link a payment to a particular service, with subsequent billing of secondary or tertiary insurance, or ‘dropping’ balances to patient responsibility as appropriate.

Batch posting of payments usually offers staff a somewhat faster way to post larger insurance checks, affording a built-in balancing mechanism as well as allowing a line-item detailed posting of payments for monitoring individual procedure codes needing resubmission or those with inappropriate reimbursement requiring follow-up. Other features may include the capability to print out an actual bank deposit ticket of payments posted to the computer system, as well as a variety of formats for report printing of payment detail for daily and monthly balancing. The ability to maintain reimbursement data or fee schedules by payor for multiple procedures is time saving and enhances accuracy when posting payments, allowing for automatic calculation of contractual adjustments as well as alerting the payment poster to inappropriate payments.

Optimum processing of insurance claims is via electronic submission directly to the insurance carrier when possible, as well as through a ‘claims clearing house’ for many commercial or low volume payors. Electronic claims processing is often included with many software packages for clearing house submissions, but ‘modules’ for direct carrier submission (i.e., Medicare, Blue Shield or Medicaid) may involve an additional one-time charge by the vendor, which is usually an expense that is well worth the initial investment. As most practices are aware, electronic claims submission affords more rapid reimbursement (10-14 days electronically as opposed to >30 days for paper claims) as well as information on claims rejection being available almost immediately as opposed to paper claims rejections, which are usually received anywhere from 4-6 weeks following initial claims submission.

Many practices still prefer processing their own paper claims for local insurance carriers as well as those carriers who don’t have electronic claims processing available yet, and a good billing system should allow not only ‘batch’ claims processing by payor, provider or date of service, but also the have ability to print individual claims on demand, as well as maintaining a “claims billing history” of all specific carrier submissions on the patients’ ledger. For patient billing functions, custom formatting capability when generating statements to patients with outstanding balances may enhance collection efforts, and at the same time reduce costs involved with the use of automated collection messages, ‘mail merge’ capabilities and numerous other features to assist in ‘pre-collection’ activity. It is important, also, that the system is able to generate a statement that is easily understood by the patient, generally one that links outstanding charges with appropriate payments and adjustments on the statement, thus providing a clear picture to the patient of the payment history of each service, outlining the amount due from the patient and/or insurance, all of which hopefully will eliminate some of the inevitable phone calls from confused patients unable to decipher their monthly statement.

Reporting formats vary greatly with software vendors, but all software affords the physician’s practice formats for many industry standard reports, such as practice analysis, account aging and claims submissions listings. Be aware, however, that in some instances, reports you may wish to generate must be “custom-formatted” by the vendor, which would most likely involve additional charges if it is possible for the information to be gathered and sorted into your requested reporting format. Some software programs will afford the practice the luxury of the self-formatting of reports, as this function may be inherent in the software set-up, and fairly easy to maneuver by the user. It is best if, when determining your needs, you also consider which reporting features may be important to the monthly operations of your practice, and then question each vendor as to the availability and cost of such reporting capabilities.

In conclusion, as you contemplate the “medical necessity” of a new or improved computer billing system, remember these basic educational steps:

1) Make a ‘wish list’ of what your practice wants regarding a hardware/software system;

2) Know what you need to be able to accomplish with your billing and management system;

3) Choose several software vendors and contact them to obtain specific information on their medical management products, as well as to schedule an actual demonstration, if possible.

Then, start shopping — just like buying a car, there are many makes and models available, so do your homework — compare features, options and overall cost, then, use your newly acquired expertise to choose the system that best fits your wants and needs.

Peggy L. Pugh, RN, MLT, CPC has more than twenty-two years experience in healthcare billing, consulting and management, and is a senior associate with Geoffrey Stillson Associates, Ltd., of Pittsburgh, PA.