Before You Outsource Internal Medicine Billing: 8 Questions That Protect Your Practice

Internal medicine appears on the surface to be a simple field. Patients attend office visits, have chronic conditions, annual wellness visits, and occasional hospital follow-up. But for all of you who have ever worked in an internist’s billing department, it is because of the volume! Hundreds of E/M claims per week, all of which rely on documentation, medical necessity and payer rules that aren’t always congruent.

That’s why it’s an appealing option to consider outsourcing, but also why it can go wrong. Giving up your revenue cycle is a major choice, and the agreement you sign will have an impact on your cash flow for years.

These eight questions will help you protect your practice before you commit.

1. How Do You Handle E/M Leveling and Documentation Review?

The place to look is office visit codes, since most of an internist’s revenue comes from these codes. Visits are leveled for the 2021 changes to E/M services, using either medical decision making or total time. Inquire about the level and how the vendor’s coders determine it, if they read through the actual note, and what they do if the documentation doesn’t match the provider’s choice. A company that only takes the level from the superbill will either undercode you (at cost) or overcode you (and open you up to audits).

2. Who Manages Modifier 25 and Preventive Visit Billing?

Inside medicine’s traditional dilemma: the patient visits the provider for a well check or preventive care visit and the provider checks out a complaint such as high blood pressure or a new symptom. Billing requires the correct documentation and correct modifier (which not only takes the right documentation but payers deny these claims often). Inquire about their approach to same-day preventive and problem-oriented services, as well as their approach to Medicare’s rules on annual wellness visits (which differ from a commercial physical).

3. Do You Support Chronic Care Management and Transitional Care?

Care management services are difficult to monitor, and many internal medicine practices miss out on money at the end of the day. The time, contact, and documentation requirements of chronic care management, transitional care after hospital discharge, and more. Ask whether the vendor bills these, who tracks the required minutes and follow-up calls, and whether they flag eligible patients or wait for you to do it.

4. How Do You Deal with Medicare Advantage and Risk Adjustment?

When a panel has many Medicare Advantage patients, diagnosis coding is more than one claim. The annual coding and documentation of chronic conditions must be accurate to ensure that patient risk scores are accurate. Ask if the company is knowledgeable of HCC coding and how they will work with providers to complete documentation gaps without adding any information that is not documented on the chart. The accuracy is important here as risk adjustment is a frequently audited area.

5. What Is Your Denial and Follow-Up Process?

All billing companies claim to follow-up on denials. What you need to know is how. Inquire about the timeframe for denial review, if they monitor denials by payer and reason and the number of appeals they’ll take before writing it off. Explain also what becomes of old claims. A good partner should be working with aging accounts receivable on a regular basis – not just when a report indicates that there is a problem.

6. What Are the Full Costs, and What Is Included?

Most of the billing companies charge a percentage of collections, which generally ranges from 4% to 8%, but sometimes it is based on a flat or per claim fee. There’s more to the number in the proposal than meets the eye. Inquire about setup fees, credentialing costs, patient statement fees, and any additional fees for reporting and/or appeals. Next, look at the overall cost of your in-house team, including salaries, benefits, software and lost revenue. Not all that comes with the lowest price tag offers the best value.

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7. Can I See Real Reports, and How Often?

You should always know how your practice is performing. Ask to see a sample report before signing, and look for first-pass acceptance rate, denial rate by payer, days in accounts receivable, and collections against charges. Monthly reporting is a reasonable minimum. If the vendor is vague or says the reports come later, that is a warning sign. Transparency at the start usually predicts transparency later.

8. What Happens If We Part Ways?

Nobody likes to plan for a breakup, but this is the question that protects you most. Review the contract to understand the length of the contract, how much notice is required, and if there is a penalty for ending the contract. Inquire as to who is responsible for the data, how fast you will be able to retrieve your files, and what will happen with open claims. A fair agreement will allow you to get out if performance drops. A hard one can trap you in and contain your information.

Using the Answers to Compare Vendors

Once you have talked to a few companies, put the answers side by side. Pay less attention to who promises the biggest improvement and more to who gives specific, confident answers about your specialty. Companies that really understand internal medicine billing services will raise issues you didn’t ask about, like care management or risk adjustment, and that is usually a good sign.

Also ask who your day-to-day contact will be. If your account is handled by whoever is free that day, mistakes tend to repeat.

The Bottom Line

You should not do this outsourcing of billing by taking a chance. You can discover how a vendor works before they even get your hands on a claim by asking the right questions. Have it in writing, request actual numbers and select the partner who treats your practice as a specialty and not a checkbox.