What to ask before you outsource medical billing

Most billing companies will submit your claims. Far fewer will work the ones that come back. The difference does not show up in a sales conversation unless you ask for it directly, because both look identical until a denial arrives.

These are the questions that produce different answers from different vendors.

On the work itself

Who reads the chart before the claim goes out, and what are they credentialed as? There is a real difference between a biller checking that fields are populated and a certified coder reading the documentation against the code. Ask which one happens on your account, by name and credential.

What happens to a denial? Ask them to describe the path a CO-50 takes through their process. A vendor that works denials will tell you who reads it, what they check, when they appeal and when they write it off. A vendor that does not will tell you they have a great clean claim rate.

How many appeals did you file last month, and how many were overturned? Appeal volume is the honest measure of whether denials are being worked. A vendor with almost no appeals is not winning, they are writing off.

On the money

What exactly is the percentage charged on? Collections, charges and net collections are three different numbers, and a rate quoted against the wrong one can double the real cost. Ask for the rate and the base together.

What is not included? Credentialing, patient statements, prior authorizations and reporting are sometimes inside the percentage and sometimes billed separately. Our own pricing is published in full for this reason: a rate that only makes sense after four follow-up questions is not a rate.

What happens if collections drop? A percentage model means the vendor earns less when you earn less, which is the point. Confirm there is no minimum that quietly converts it into a flat fee.

On access and exit

Whose system is it? If the practice management system belongs to the vendor, your data leaves with them. If it is yours and they work inside it, you keep the history. This is the question people most regret not asking.

What does leaving look like? Notice period, who works the outstanding accounts receivable during the transition, what format your data comes back in. Ask before you sign, because the answer is much harder to negotiate afterwards.

On handling patient data

Every person who touches patient records should be working under a signed business associate agreement, with access limited to the accounts they work and every view logged. Ask to see the BAA, the training records and the access logs. A vendor that cannot produce all three during a review is telling you something.

For the longer version of this, with the industry benchmarks to measure a vendor's answers against, read how to evaluate an RCM partner before you switch.

If you want a straight comparison against your current numbers, send a recent remittance sample through the contact form and you will get the analysis back. What we do and where it stops is set out across the six services.