Here he talks about some of the challenges related to out-of-network billing and offers his insight on the current climate of revenue cycle management. Read on:
Can you tell us the story behind VGA Billing Services?
My business partner, Paul von Gahl, and I started VGA Billing in 2007 as the “anti-billing service” billing service. Paul had been an independent consultant for many years transitioning providers away from outsourcing and towards efficient in-house billing. I was one of the employees he hired to replace a medical biller at one of his consulting clients. After a few years of working together, we decided to create a company that combined both consulting and ongoing billing support to serve providers who were interested in a strategic partnership, rather than the typical anonymous billing service. Many of Paul’s existing clients came on board with us and have been able to grow comfortably ever since.
What do you feel differentiates your service and sets you apart?
We target the niche market of out-of-network surgical specialists in private practice. These types of claims typically reimburse very high, but are also the most difficult to collect. There are many levels of red tape, internal edits, pricing discrepancies, etc., that require a high level of industry knowledge and expertise not found in the standard doctor’s office or outsourced call center. As a part of our billing service, we also provide advice and direction on company growth, administrative support, marketing and finances.
Tell us your story. How did you get into revenue cycle management?
I was originally focused on theater, music and film, but accepted a job as an administrative assistant at a medical practice. That is where I met my business partner, Paul. I was able to learn quickly and move my way up into management, where a steady paycheck suited me much better than the guessing game of the entertainment industry.
Can you talk a little bit about the landscape and complexity of your billing?
Even though we are an outside service, we put just as much focus on the in-office front-end operations as well as the back-end billing process. Fifty to 60 percent of denials or rejections can be avoided altogether if the proper systems are put in place on the front end. Half of our operation is dedicated solely to the implementation of policies and strategies, and the education of the front office staff of our clients. Also, as each of our clients has a different need and circumstance, we do not have a cookie cutter solution. The policies, strategies and protocols for each client is completely different, requiring a VGA staff member to be able to completely switch gears from one minute to the next.
What are some of the specific challenges related to out-of-network billing?
As the reimbursement amounts out-of-network are usually much higher than in-network (sometimes the difference between $6,000 and $40,000), insurance carriers make them much more difficult to collect. There are a variety of unpublished and unknown internal edits, third party contractors and double sided red tape that has to be navigated.
What’s your plan to stay competitive with major players like Athenahealth, eClinicalWorks and McKesson?
When it comes to out-of-network medical billing, there is only so much that software, data analytics and coding knowledge can accomplish.
Much of what we know and what we do is not taught by any medical billing, coding or certification course. It is information learned through intense follow up and investigation on claims processing. At the end of the day, it takes an actual person on the phone who is able to navigate through the various internal edits, third party pricing companies, third party medical review companies and overpayment auditors, to get a claim properly paid. The major players are typically not set up to provide this kind of service. Any problems beyond a second submission or second inquiry on a claim are not cost effective for them to pursue. It is not unusual for a complex follow-up phone call on a stuck out-of-network claim to take anywhere from one to three hours, and this would put major players in the red when it comes to the hourly productivity of their employees.
Additionally, we do not require or limit ourselves to one type of billing software. Our clients can keep their existing EMR or PM, which we work out of, or, we can recommend or provide software for them.
How has the Affordable Care Act affected your business?
Due to the enormous volume of people, New York City is fairly insulated from the healthcare climate of the rest of the country. So, the ACA has not had a huge effect on us. That being said, the ACA is designed to provide more care and cut costs, which does not leave room for the out-of-network provider.
What about patient pay. What has been the impact on your work?
Patient deductibles and other out of pocket expenses are always on the rise, especially with the ACA plans. Patients that go out-of-network, however, always expect to pay more out of pocket, so the impact on us is not very substantial.
What headlines or trends in the world of revenue cycle management are you following today? Why do they interest you?
I’m interested in the new MACRA initiatives. I think desire to move away from fee for service into a reimbursement model based on quality measures is misguided. All Meaningful Use, ACO’s and PQRS have accomplished so far is an increase in overhead expenses and the administrative burden for providers. The data is flawed on two levels:
1. There is too much of it, by the time is it analyzed and quantified it is out of date.
2. It is partially reported by a series of codes and modifiers that can be easily manipulated to show the best outcome and net the highest reimbursement.
I feel that this endeavor is a waste of time and resources, especially when the goal to move away from volume towards quality is already being hampered by a shortage of physicians and an increase of the insured.
What predictions do you have for the future of revenue cycle management? How will the field evolve?
It appears as the industries on both the provider side and payer side are moving more toward automation, either in the form of software and digital processing or outsourced call center employees reading off of a computer screen.
As I mentioned before, there is only so far automation can take you before you start to loose quality and money. For example, an issue that used to take five minutes with an insurance representative now takes 20 minutes, due to the use of cheaper, untrained call centers. On the provider side, automatic posting (ERA) and other one-click solutions allow underpayments, specifically for out-of-network providers, to fly under the radar. I imagine that there will be an increase in consultant work on both sides to constantly review the systems in place and develop new solutions.
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Last Updated on October 19, 2016