Medical Billing Blog

On August 22, 2011, the Availity (Blue Cross/Blue Shield) Web Portal upgraded to the 5010 format. MedPro Solutions (a billing company located in Pensacola, Florida) submitted $48,000 in charges ( 90 claims) through the portal  for processing.  One of the touted advantages for using the Availity product is the ability to view immediately whether the claim is considered a "clean claim" or will be denied for some reason.  The claims submitted by MPS were in the appropriate 5010 format (MPS having upgraded to 5010 format previously) and the expectation was clean claims

Recently a physician contacted MedPro Solutions looking for billing information.  He was interested in outsourcing billing as  his software vendor was not ready for the 5010 upgrade and were going to charge him $35, 000 to accomplish; something they had not yet taken through beta.  Amazing news as the go live deadline for 5010 compliance is January 1, 2012.

"The purpose of a bureaucracy is to successfully implement the actions of an organization of any size (but often associated with large entities such as government, corporations, and non-governmental organizations), in achieving its purpose and mission, and the bureaucracy is tasked to determine how it can achieve its purpose and mission with the greatest possible efficiency and at the least cost of any resources."^[1]

The American college of Physicians has stated that "e-health activities have the potential to transform the health-care delivery system" and "advance the patient centered medical model.

Denials continue to plague practices from federal and commercial payers.  Analyzing and trending denials are important for two reasons:

 "After a lifetime in the business world my post-retirement work has been in the health care environment and I am amazed at the un-businesslike practices I have observed. I could rant for a page or two about percentages, budgeting, write-offs and stuff, but cutting to the chase my impression of what passes for “billing” is “throw a bunch of sh** against the wall, see what sticks, and write off the rest.” It makes my head swim to think about it. From what I have seen, the quality of healthcare is tolerably okay but the business aspect is an economic train wreck."

I hear it all the time...."I'm too busy....."  The provider health care side of the industry is scrambling to upgrade software to accommodate 5010 requirements.  Providers are trying to figure out how ICD10 will impact their well learned coding practices and IT departments are implementing EHR's to already full plates.  Meanwhile, the hospital side of the industry is forming alliances of one sort or another with physician practices. Establishing new contracts and combining accounts receivables.

To those of you who believe that politics has only recently set out to control health-care costs and operations; a brief look at the history tells a very different story.

Health care billing managers are under tremendous pressure to be "best in class" with their billing operations.  To accomplish this goal, managers must keep several balls in the air at the same time deftly juggling multiple people and issues to accomplish this goal. Of course managers must have good communication skills,  both written and oral. Of course managers must take accountability for the operation of the business office and of course the manager must have thorough knowledge of how accounts receivables is handled by their practice management systems.

While there is  no denying that medical billing is complex and sometimes confusing; we tend to make it "rocket science" instead of developing strategies to cope simply and clearly with insurance and lawmakers demands that are thrown at health care billing operations every day.