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The age old question of how to set fees for your Billing Service

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I am doing cold calling to providers and what i found is that most of the doctors are doing their billing inhouse. Is there a good rebuttal i can pitch to doctors who are doing their billing inhouse?

Are you speaking directly to the dr?  I would be asking if they are having any issues.  Most offices that do the billing in house have some issue.  For many it is turnover of staff.  If that is the case I would come back with it's hard to hire someone with experience, and even when they have experience you really don't know if they are good.  I also state that it saves them on having to find someone, saves on payroll, taxes, etc. 

If they have someone and that person has been there forever, they are less concerned with those issues, but they may have other issues.  That person has other duties that take them away from the billing.  In this case I push the working of the aging report.  Most offices do not get to this, and a lot of money is lost.  If this is the case I tell them that our fee is usually covered by what we collect for them that they are currently missing out on. 

There are other issues with in house billing like keeping up with changes, clearinghouse issues, etc.  Also, the person may be good, but not understand coding.  Or maybe they don't know how to handle denials or don't have time for denials. 

The key is to find out what isn't working and show them how you can fix that problem.

If everything is working perfectly (which it hardly ever is, but sometimes they won't admit it) move on to the next one.  It most likely will not be a good account.


--- Quote from: HeidiK on May 29, 2014, 03:07:28 PM ---Hi Everybody!

As a medical billing service, I was asked recently what my charge would be "per claim" and I hadn't heard this term in a verrrrry long time!  I reached out to Linda Walker and Merry Schiff who both gave me some insight but I wondered how others in the field might respond to a request like that.

It's a different concept that was used back in the day when an office might only want someone to enter their claims and submit claim electronically.  I believe it was popular when most offices didn't use computers but wanted the quick turn-around for their reimbursement.  Crazy to believe, but that was only in the last 20 years or so! 

Now that pretty much everyone has a system in place, a "per claim" fee is hard to determine because you have to consider what is involved.  I came up with the following levels and wondered if anyone would like to offer their opinion on what you would charge for each level, and if you think other items should be listed or taken out.

TIER 1: CLAIMS PROCESSING   _____ per claim
   Submission of primary, secondary or tertiary commercial claims with required attachments when needed. (Each claim is charged individually)
   Submission of Workers Compensation claims and No Fault claims
   Posting patient and insurance payments for all claims filed
Analyze explanation of benefits statements from insurance companies and verify accuracy of payments. 
   Notification to the office when claim(s) are determined to be rejected, denied or paid inaccurately.
   Claim status review for all claims 35 days past submission date.  (Refiled claims are handled as a new claim submission)
Monthly Patient Statements printed and mailed, office handles patient phone calls

TIER 2: PRACTICE MANAGEMENT    _______ per claim
   All services as listed in TIER 1
   Toll-Free number and secure, encrypted email for patients use regarding any and all questions pertaining to billing.
   Monthly report of claims submitted, payments and adjustments applied.
   Quarterly review and report of Revenue Cycle Management Process
   Review and correction of billing errors when claims are rejected, denied or paid inaccurately and/or query to doctor for additional assistance when needed.

   All services as listed in both TIER 1 and TIER 2
   Certified Coder review of records to verify documentation supports claim, query to physician when addendum is warranted.
   Customized design of coding and billing forms and reports.
   Yearly Fee Schedule Review with Coding Updates
   Monthly Eyecare Professional Newsletter with billing, coding and marketing tips
   Discounted rate for subscription to
   2015 ICD-10-CM Update to System and applicable forms (Training available separately)

   Service available separately or in addition to any of the Tiers listed above. Current demographic and insurance information must be provided.
   Active coverage is verified online, and then a live call is made to the carrier to obtain details of patient coverage including patient and/or family deductible, out-of-pocket expenses, material allowances and eligibility.
   Completed EB Form will be sent back to the office prior to the patients scheduled appointment.  Copy should be given to patient when they check-in so they are aware of the full expected payment at check-out.
   Office will be notified immediately for patients who are found to be ineligible for have terminated coverage so other arrangements can be made or appointment cancelled.

I'm looking forward to seeing what everyone thinks, but please include how long you have been "in the business" with your post.  I think it makes a difference and hope to keep this topic informative and helpful.  :)  Thank so much and have an amazing day!

--- End quote ---


We typically charge a percentage of what we collect, that way it incentivizes our people to place an emphasis on clean claim submission and working denials.  I do like the Tier Model though, because I'd love to find clients where we could just submit claims for them through their medical records and charge them a fee for that.  I'd be interested to know if many clients would take me up on just offering a "Tier 1" type service?  Anyone have any experience with that?

There are some providers out there that just want what Tier 1 offers in the model below.  However I have been doing this for over 25 years and I find that most providers want more.  We do have a couple of out of network providers who only want the Tier 1 services, but over 95% want payment posting, aging, denials and appeals, and patient billing as well.


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