Medical Billing Forum
Starting a Medical Billing Business => Starting Your Own Medical Billing Business => : KathyG November 01, 2011, 10:57:38 PM
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Hello, All! I'm basically new to this...although I have been billing for a Friend/Provider for a while now...with very good results. I am now ready to launch my own billing business in NJ focused on mental health. There a few things I'm hoping those of you who have been "in the trenches" for a while will be able to help me with.
First, could anyone more clearly define what is basically known as a "per claim" or "fee for service" billing structure? I understand that the fee is based on the number of encounters/claims submitted and there is no tracking of the claims submitted, but do you usually post co-payments and insurance payments to client accounts (or do anything else) under this arrangement?
I was thinking of having a fixed-rate based on the number of encounters per month. For example, a provider for whom we submitted 1-40 encounters per month would pay a fee of $200.00 for these basic services. If they would like to have other services, such as confirming eligibility and benefits, securing prior authorizations, etc. they would pay an additional fee which would be based on the actual number of encounters submitted during the month. The following calculation would be used for a provider who actually had 35 encounters during the month:
Calculation: Monthly fixed rate + actual encounters x $X = Total Amount Due...or in this case
$200 + 35 x $X = Total Amount Due
Could anyone recommend a reasonable dollar amount for this additional level? Any other thoughts you might have would be appreciated. Also, does anyone know if percentage billing is a "no, no" in NJ?
Thank you!
Kathy G.
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How you price your services is really up to you. Personally I like the flat fee model because i get paid for all of my time. The one thing I don't like about per encounter or per claim charges is that it seems to take away something professional.. it's more like a "menu" because you might have a client that wants full practice which might include benefit verifications, follow-up, appeals, etc. So if you were to do that you would need additional fee's for those services and that again, would result in a "menu" type and provider's don't seem to fair well being nickle and dimed. If you take a look at some posts on the forum you'll see some examples of flat fee model's which more and more billing companies are moving to. Percentage based billing is not prohibited for doctors in NJ, however again, more billing companies are moving away from it because of the potential of it becoming illegal in the future and based on the OIG's recommendation to stay away from it. Some billers will argue that it takes something away from them in marketing, by not being able to say "We don't get paid until you get paid" but really, this economy sinks that notion from the get go and I really believe provider's are fully going to comprehend a more professional way to charge for your services AND your time.
Oh in NJ you have to register with the state as a third party billing company. You can find the link and instructions here: http://www.state.nj.us/dobi/division_insurance/managedcare/tpapage.htm#tpb BE SURE YOU FOLLOW THE DIRECTIONS EXACTLY because they will send your paperwork BACK! There are fines and penalties if you do not register so don't miss this very important step!! In the beginning it was very simple, but now it's become quite an involved process and you must do this BEFORE you take on that first client. It's a very well known regulation so providers WILL be asking for your registration from the state and it will not look good if you have not done the process. The requirements are a business plan, projected earnings, contractual obligations, marketing plan, listing of all contractors/employees (includes clearinghouses) along with their contracts, Insurance policies, bonds if needed, etc. Be aware that providers are even now given a place right on line to make a complaint against a NJ Third Party Billing Company.
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Thanks, Linda!
I did all I needed to do with the State of NJ. I was ready to launch earlier this year, until I discovered that I needed to file all the things you mentioned. Glad that's behind me.
I just wanted to "pick you brain" a little more about setting a flat fee, as you advised. I realize you can't give me a perfect number, but if you could give me a "ballpark" figure it would be really helpful. What would be a good "starting point" for billing for mental health services (no psychiatric service providers at this point) for a provider with less than 15 clients/encounters per week? I would be billing per encounter. Does $300 sound reasonable to you, or do you think it should be lower? As you advised in another posting, I would be charging separately for postage, envelopes, etc.
You also mentioned that for every 7 clients the provider adds you up your price $40. In the example you used earlier today you mentioned you charged a flat fee of $800 for a client you knew would involve 18-20 hours of work each week (plus your postage and other costs). Could you give me the number of clients and/or encounters this account involves? If this client's billings took you 8-10 hours per week, I assume you would set your rate at $400...and add the other costs. Is that correct?
If you could give me any idea of a starting point for a small mental health practice with limited codes involved and averaging between 10-15 encounters per week, it would really be helpful. :)
Thank you!
Kathy G.
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Kathy, my number wouldn't match because I don't do it per "encounter" the main basis of my flat fee is based on hourly rate (what I can do in an hour, on an average). My flat fee also includes all my costs for that client so I do a full analysis of the practice. There is another reason for the all "inclusive" fee.. generally someone acting as a "Private contractor" vs. third party billing company will break out these costs separately, even an "employee" (rare and non profitable for the provider) would break those charges out and could impact the provider's Tax return. I found this out when a biller I was working for got a call from the provider's accountant asking her to create an "all inclusive fee" rather than breaking out costs, something to do with the provider's itemized deductions. Basically your hourly rate might be different as well as how many claims you can process, on the average in an hour. Using your numbers ..here is how "I" would compute "MY" monthly fee for this type of provider.
$25 per hour. Average of 6 claims per hour =$50.00
Costs for clearinghouse: @avg of .35 cents per claim $5.00 (small wiggle room)
Postage, claim forms, envelopes, phone: $150 (This is JUST rough estimate from top of my head!!!)
So you wouldn't be too out of line with this number. Based on how my flat fee is derived, I never let the provider know it's based on that hourly rate, there's no need for them to know that. Now, if your going to charge your expenses separately in addition to the $300, I'd have to say that might be a little high for such a small provider. Expect never to get rich and even have hard time breaking even with mental health unless you have a few Psychiatrists.
Again, remember that how you want to charge (per encounter) is going to change my example and if you are going to charge separately for things you shouldn't even use my numbers. If I go by you wanting to charge by encounter, I'm coming up with $20 per encounter (300 divided by 15 ) and that seems extremely high which again, is another reason I prefer charging flat fee based on hourly rate minus costs. The average per claim fee is $4-$6. I am assuming your per encounter is a "per claim".
NOW another thing to consider (to confuse you more) is that small mental health providers are "ok" submitting patient claims on monthly basis which means you could have 1 patient with 4 lines of service dates on one claim. Breaking it out per encounter may cause provider to think they could save money by giving you work monthly. MH provider's a bit "frugal" ::) With your fixed monthly fee based on hourly rate, your getting paid for the TIME you put in.
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Thanks, Linda. Still a little confused, but I think I'm getting closer. Since you charge about $800 for 18-20 hours of work...and I read in a book that for about 12 hours of work for another biller that their charges came to about $750 per month, I'm trying to "back out" of both these figures to get my flat fee amount. Here is what I came up with last night after I sent you my last message:
01-13 encounters per week or 4-52 encounters/per month. All inclusive flat fee of $200/per month.
14-27 encounters per week or 53-108 encounters/per month. All inclusive flat fee of $400/per month.
28-40 encounters per week or 109-140 encounters/per month. All inclusive flat fee of $800/per month.
What do you think of this fee schedule? It really doesn't seem worth it to charge any less than $200/per month...if you're checking eligibility & benefits, getting prior authorizations, and sometimes chasing down information from the provider! Right now I seem to spend a lot of time "chasing down" my Provider/Friend for information, but it has been a great opportunity to learn in so many ways...so I let him slide to an extent.
I'm targeting single providers, who usually don't have any support staff at all, and I know if they are not consistent in providing the necessary information, it can get time consuming for the biller. I am confident in my work and I don't want to deal with anyone who is going to be bickering over nickle and dime type issues. They will be getting their money's worth and more if I handle their billings. Since I started doing electronic billings about two years ago, repairable claims from the clearinghouse and insurance denials have been basically nonexistent.
Due to "word of mouth," two providers recently approached me so I really need to get my act and rates together!
I'm limiting my work to mental health right now (no psychiatrists) because that's what I know and feel comfortable with. Once I get a good handle on everything, I'll expand to psychiatrists. Since my husband is a psychiatrist, I should have some advantages there with regards to networking:) I'll also expand to other specialties once I'm more sure of myself, especially with all these changes taking place in the system beginning in 2012. My son also takes his Certified Professional Coder exam in December, which will be helpful.
Could you take a look at these latest figures and let me know what you think? Thanks sooooooooo much!
Kathy G.
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01-13 encounters per week or 4-52 encounters/per month. All inclusive flat fee of $200/per month.
14-27 encounters per week or 53-108 encounters/per month. All inclusive flat fee of $400/per month.
28-40 encounters per week or 109-140 encounters/per month. All inclusive flat fee of $800/per month.
I think I'm getting hung up on your definition of an "encounter" vs. a "claim". I'm very anal with details and this could matter if I were to give you advice. I look at the big wide range of 4-52 and I am just not understanding. Can you describe to me what constitutes a claim for that provider vs. encounter as a "visit"? Like I said, some mh providers will want you to bill a patient's full month of services (4 visits if seen once a week) on one claim form if a biller is charging per claim. When you say "Per encounter" it's not really sinking into me what time you will spend doing what. For example, will you just enter the encounter, wait for 6 service lines or a month to file "A" claim? or will you enter and bill each encounter as a claim? Also what is your average time spent submitting claims (Clean claims) I hope I'm explaining this right. I read your examples as an encounter being "one" visit, but I'm not really getting a clear picture of how you will be submitting charges, recouping time for new patients demographics to be entered, etc. Because my figures are based on my time and then I minus out costs, I don't really HAVE a set pricing schedule. I go into the practice and I do a full analysis and then also run costs so that my flat fee is fully inclusive of my time and costs involved PER client. where I gave the example of 18-20 hours.. that's after I have looked at the practice, specialty, etc..
What do you think of this fee schedule? It really doesn't seem worth it to charge any less than $200/per month...if you're checking eligibility & benefits, getting prior authorizations, and sometimes chasing down information from the provider! Right now I seem to spend a lot of time "chasing down" my Provider/Friend for information, but it has been a great opportunity to learn in so many ways...so I let him slide to an extent.
No, and I agree, less than $200 wouldn't be worth it for many of us.. however one of my oldest and dearest clients I still bill for is only in his office (he's a teacher) once a month, and he only sees a small load of patient's every month. Also.. Just something to think about.. if you are billing for therapists, psychologists, your actually doing more than you would the average psychiatrist would.. Psychiatry is straight forward, your just changing the CPT (even numbers I go by <g>) and using the med management codes of 90862 and M0064 in addition. The better money is with the psychiatrists of course because of their degree vs. therapist, LCSW, and even PHD. Also many psychiatrists visit hospital's and nursing homes as well which is also pretty standard and straight forward. I guess what I'm trying to say is , don't LIMIT yourself.. not even starting out, your ready for it as it's not much at all different from what your doing.
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Linda,
I'm really making myself dizzy at this point...and I'm sure you're feeling the same at about this point! ;D Thanks for bearing with me...and maybe this will help someone else who is struggling with this issue. Okay, this is my latest beakdown...and I hope it's my last! After I sent the last email to you, I thought there was too much of a gap as well between the previous 3-tiered pricing structure I gave you. Under this new version, once the provider's monthly encounters/visits billed increases by 20/month, they will move into a higher pricing category, which will be an increase of $100/month. Hold onto your hat, cause here we go again!:
>01 and <10 encounters/visits per week = $200/month
>01 and <41 encounters/visits per month
>10 and <15 encounters/visits per week = $300/month
>40 and <61 encounters/visits per month
>15 and <20 encounters/visits per week = $400/month
>60 and <81 encounters/visits per month
>20 and <25 encounters/visits per week = $500/month
>80 and <101 encounters/visits per month
>25 and <30 encounters/visits per week = $600/month
>100 and <121 encounters/visits per month
>30 and <35 encounters/visits per week = $700/month
>120 and <141 encounters/visits per month
>35 and <40 encounters/visits per week = $800/month
>140 and <161 encounters/visits per month
Essentially an encounter is a visit, as well as a claim. Normally, clients are seen once per week by the providers I'm currently targeting (LCSWs) so I'm considering each visit as a claim. I'm billing weekly to "keep the money flowing" for the provider. I also don't like to bill infrequently and will not take on clients who want to stockpile their claim billings until the end of the month. I think it's especially important when your keeping track of the RFT's for a provider. If there's an type of error, you've already lost a month. Once I move on to the psychologists/psychiatrists, I'll need to come up with another formula, I guess.
I believe my costs should be covered enough and it basically breaks down to $5/claim using the highest number of encounters/visits in each separate level, which will include prior authorizations, client statements, etc.
So what do you think??? Is your head whirling???
Thanks...
KathyG :D
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No head whirling, I just needed to see how you were billing (per claim/per encounter) :) Now knowing that and without the large gap.. those are more in line.. The thing that concerns me (AND THIS IS JUST based on my experience and a tip only, not meant to do anything but advise :)) is that it's still somewhat a "menu" of services/prices. Will this be something you propose to a particular client or do you plan to offer this pricing schedule to all potential clients? I started my business in NJ back in 1996, I still have a few clients I do consulting with there as well. It was just my experience that presenting a "menu" or "ala carte" of pricing services intimidated many providers. When you tend to break it down and it's $5 a claim, that just may be undercutting yourself for some clients because they are all not the same. Again, I started out in NJ and also with mental health and NO two practices were alike in any way. I had small providers with big problems and large provider's with little or no problems, etc. But this is JUST based on my own experience, if this does work for you than you should continue. I don't know what area you are in ..but as a rule of thumb..the further North you go in NJ (closer to city) the higher the rates.. so $5 a claim might be "ok" for south jersey but really low ball figure moving into even central jersey and North Jersey.
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Yes! I'm almost there :D
These figures are more for my own use to set my fixed fee...and help me with these first accounts. My first two perspective clients approached me, thanks to my Provider/Friend, so I'm now under pressure to "get my act together" and finally set sail! I'm not going to show any perspective client these figures. If I go in a little low on the first two, I can live with that as they will "spread the word" about my services. Your input has really helped me feel more secure about the figures I'll be presenting. The first client does happen to be located in S.Jersey, so that helps too. I may "bump" each one up $25-$50. Thanks to you, I feel confident now that I'm setting rates that are neither too high or two low. As you said, each practice will be different and each will be a learning experience, especially in the beginning.
When I write my contract, how would I handle growth issues? For example, this first client does not take insurance now. He's doing mostly group work with court ordered participants and cash payments. Once he is credentialed, the practice will be changing. He intends to expand his practice beyond the current focus on substance abuse and the number of clients and insurance claims will increase over time. Is there some type of clause I could insert into the contract that will address growth issues?
Thanks, Linda...
Kathy G.
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Perfect.. yes you are on your way :) :)
As for the contract, you will be spelling out each contract with how you charge, your sliding scale should be addressed there. In regards to any practice growing, you can include an option to "re-evaluate" in 6 months or even offer the first 3 month trial period under contract with clause to adjust/re-evaluate in 3 months. IF your sliding scale incorporates fees to accommodate the growth, you wouldn't really need a separate clause. Just be sure to have an attorney review your contract, but it sounds great so far. Your thinking of everything and that's always a good thing.
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Thanks, Linda... and thanks for the vote of confidence with regards to moving on to include psychiatrists :)
Kathy G.
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Hi
I am new to the Med billing Biz and i wanted to know is it illegal to charge percentage in the state of AL.
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I'm not sure about Alabama. Never done billing there. If you are new though you should really consider other methods of charging. I know it is the most widely used but any experienced biller can give you a laundry list of reasons that it is not the best.
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THANKS...AFTER READING A FEW MORE Q&A I AM GOING TO USE ANOTHER FORMULA TO COME UP WITH MY PRICES....THIS SITE IS VERY HELPFUL...THANKS SO MUCH. :)
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Sorry, just starting out as well...so we get paid % or flat rate fee depending on the claims we send out, right? Or is it on what claims actually get paid?
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That is really up to you. It must be spelled out in your contract. You need to decide how and on what you will be paid. Most services that charge a % (which I am not recommending) charge it on what is paid. If you are charging a per claim, it is on what you send out. And if you charge a flat fee you would base it on all the work you do.
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Thank you for your reply Michele, it was very helpful! Since this post I have purchased and read your book on pricing and it was extremely helpful!
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Glad to hear, that's what we wrote it for! ;)
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I have more questions now. I thought I had everything set but my boss (owner) of the company wants things a bit different so now the pricing seems to be a bit confusing. I was trying to come up with fees that were flat rate but being that she is in collections she wants to use % rates, which is fine in our state. When I took training with my software company, the lady told me if I use percentage that rates should be different for surgeons as they make more money and should be charged less. I have also been told to make sure I get paid for copays if I am doing A/R because I need to input it in my software and track it. We do not have a set client yet but we do have clients from our collections side that keep asking us when we will be ready. They are all different specialties, which is fine but I don't want pricing to be confusing. This is what I have so far which I think needs to be amended.
One-time Non-refundable setup fee of $500-$1000 (time, services, setup)
PAC’s (Past Age Claims) 90 days or older= 12%
For non-surgeons :
6% of each claims processed
3% of each co-pay:
Patient statements: 3% of each statement
Surgeons
One-time Non-refundable setup fee of $500-$1000 (time, services, setup)
PAC’s (Past Age Claims) 90 days or older= 12%
4% of each claim processed
2% of each co-pay
Patient Statements: 2% of each statement
Thoughts?
Thanks!
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Sorry, just starting out as well...so we get paid % or flat rate fee depending on the claims we send out, right? Or is it on what claims actually get paid?
The latest consensus is that this model of pricing is phasing out, billing companies using this model are not being reimbursed for all their efforts/time. BUT if you are going to do it, then what you base it on depends on what you put in your contract. Your contract should be VERY detailed and specific. Some billers using that model charge based on % collected and others based in on just % of collections collected from insurance carriers. Again, you want to make sure your contract is VERY clear.
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