First Potential Client Has an Offer - Advice Needed!

[Bill the Biller]

I have the following question which I posted in a different topic but I got no responses, so let's try in a new topic:

I am currently looking around for my first client, I have built a nice portfolio, nice marketing materials, website and all that. So I have been to an office a few days ago and I called to follow up, so the doctor tells me, I want to test your skill, you can take 100 rejected claims and see if you can process them then I know you're the right person for me. Otherwise, maybe you have a 0% success rate.

I told him it's the first time I came across an offer like this, but I can think about it and I'll let him know today.

Now, there is so much going through my mind.

Is this something I can technically do, why can't he process them on his current system?
What's with that pile of claims, he wasn't just waiting for a billing company to call and ask him to do it for him.
Can I credential with the payors just for the sake of a test?
Perhaps he really wants a billing company and wants to start just like that?
If I go for it, what questions should I ask him? Like whether he processed them himself already through any software? Or just take it and shut up?
Do I need some kind of agreement? Perhaps he will say thank you and just smile at me?

As you can see I am a bit overwhelmed with his offer. On one hand, he's a potential client (he says he collects over $1m annually). On the other hand, I have all these questions above.

You folks are wonderful in setting things straight, please come forward with your kind advice.

[PMRNC]

So many factors to consider in this scenario...

First you should explain to him all the compliance that goes into being a Business Associate, explain to him it's not cost effective nor practical to be a "temporary" biller. You will still need ALL of the compliance requirements, not to mention software, clearinghouse setup. written policies procedures, Risk analysis, BA agreement to adhere to all the compliance components.. etc. EVEN for that first client I'd most likely PASS on this deal, however I have a pretty good resume and references. If you are brand spanking new, I'd suggest maybe a compromise. Offer to come in and look at claims and offer solution. Maybe offer 1-3 hours of your time. You'll still have to do a standard BA agreement but you won't have to worry about software and clearinghouse setup. Not to be a negative Nelly but in my experience it sounds like he's looking for a freebie.

Another thing to mention, is that if you hold any certifications, tell him that you have already completed these certifications and that you feel your experience and knowledge does not need further testing. Don't be afraid to say no.

[RichardP]

... you can take 100 rejected claims and see if you can process them ...

I don't think there is enough information in your comments here to respond properly, so I'm going to propose the following.  Adapt it to fit the specifics of your situation.

1.  Linda listed all the things you must do to be somebody's biller.  Don't bother with those things for now.  Rather, sell yourself as a consultant for a specific project (working 100 rejected claims).

2.  I assume someone has been doing the provider's billing - even if it is the provider himself (not likely if he is pulling in over a million per year).

3.  Sell your services to the provider at $35 an hour.  Promise to make recommendations to his biller - and let the biller be the one to actually re-process the rejected claims.  (This configuration puts you in the position of detective and advisor, not biller)

4.  Get the EOBs for the rejected claims and see what the codes are for why a given claim was rejected.  If you have an Excel spreadsheet, use that.  One column for patient account number, if any; one column for last name of patient; one column for primary rejection code; one column for short description of primary rejection code.  This way you can sort on any of the columns and develop an idea of the kinds of groupings you have.  That helps with giving the provider feedback about what might need to be changed in his coding process or billing process.  e.g.:  Do you have 100 different rejection codes?  Do you have 75 rejection codes of one kind, with the remaining 25 rejections divided among 4 other rejection codes?

5.  Bundle like rejection codes with like.  Place a note on each bundle that briefly describes what is needed before the claims can be re-submitted.  That information would come from the rejection code.

6.  I assume you can do Points 4 and 5 with relative ease.  If you cannot, then you have a clue about what you need to work on.  If you cannot, you might tell the provider that you will work for free if he lets you assist his biller in the doing of real-world stuff (process knowledge) versus just learning things from textbooks (content knowledge).

7.  If you run into rejection codes that you cannot figure out, come back here and state the codes you need help with.  Someone will no doubt show up to help you come up with a proper approach for resolving the issues surrounding a given rejection code.  (Of course, there really is no proper approach if the reject code is "lack of timely filing".)

Sell yourself in this way to other doctors.  If they take you on (for a specific project), you will increase your understanding of the billing process.  And, if you are any good, you will develop some word-of-mouth buzz from the providers re. your abilities - which will be useful in gaining clients of your own as an independent biller.

[kristin]

I would clarify first if these are rejected claims, or denied claims. There is a difference. The provider could be using the two terms interchangeably, but should not be. Rejected claims are those that don't make it to processing by the insurance companies when sent electronically, they reject at the clearinghouse level. Denied claims are those that do make it through to the insurance companies, and then deny for any number of reasons.