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Evaluating Medical Billing Services – A Brief Guide

>> Sep 19, 2016

As a medical services provider, you would want to focus solely on the patients and leave the other aspects of administration and billing to specialist service providers. However, the evaluation can be pretty difficult if you do not know what to look out for when outsourcing your billing. If a proper selection is made, you can avoid an unreliable fly-by-night operator and opt for an agency that you can trust so that you can increase the time spent on caring for patients. Some handy tips on getting it right:

What to Expect From a Billing Service Provider?

Typically, a billing services agency should be able to handle all the functions related to the billing process in the office of the provider such as generation and submission of claims, follow-up with insurance companies, posting and processing of payments, patient invoicing and transfer services of collection agencies. Some of the most vital tasks performed are following up with the insurance companies for payment and chasing claims that have been denied. Some other services that many agencies also provide are credentialing, coding and transcription, verification of insurance eligibility and scheduling of appointments. As a medical services provider, you will need to figure out which of these services is your priority because the amount of professional fees will increase with the number of services provided.

Service Level

Before plumping for a service provider, you should be able to figure out the scope of supply so that you know what exactly the service provider is responsible for and what you have to handle on your own. If the agency has promised to pursue denied claims then you should make it a point to examine their procedures for doing so to find out if they are competent. The agency should be able to follow-up with patients who have not paid their bills as well as comply with the provisions of Health Insurance Accountability and Portability Act (HIPAA) to ensure the protection of patient information and privacy. Find out if the agency is willing to provide feedback on how to improve your practice. It is critical that a proper understanding is reached regarding the scope and level of services to prevent unnecessary disputes, friction, and financial damage.

Industry Experience

When evaluating an agency’s credentials, you will need to look beyond just the number of years of experience that the provider has. Apart from functional experience, they should ideally be familiar with certain specialties as billing procedures vary a lot with the specialty. It pays to have a service provider that is familiar with your specialties as well as billing to Medicaid and Medicare. Check for the relevant billing certification and not go by just claims. Checking whether the service provider’s personnel are certified by the American Medical Billing Association (AMBA) can lend an added assurance of competence in various aspects of billing, technology, and compliance.

Deployment of Technology

While you need to check whether your agency is using billing software that is sophisticated enough for your requirements, you should also check whether they are following the correct procedures. You should also investigate the policies and procedures of the service provider with respect to sharing of information, data security, and backup and recovery procedures. Remember, the technology used should be HIPPA-compliant. The right technology can mean the difference between making a profit or a loss.


Depending on the sale of your revenues, choosing the right pricing plans can translate into savings of thousands of dollars. Typically, agencies operate on three pricing models. Among the most common is a percent of their collections or even gross claims that are submitted. This model has a problem that many of the smaller claims may not be pursued as aggressively as warranted as the payoff is lower. The fee-based model that envisages a flat fee per submitted claim can be quite cost-effective, however, the agency can tend to neglect following up on claims that are denied. A hybrid model builds in a flat fee for some insurance companies and a percentage for others. The percentage option is the most common but typically almost all agencies will offer the other options too to customers.


Getting your thoughts in order before proceeding to go hunting for a billing service provider is crucial. You should preferably study as to what is lacking in your internal setup, and proceed to ensure that the external agency will be able to cover those deficiencies and boost your efficiency and profitability.

Author bio: Gary Willis is the head of a large medical services provider. He has successfully outsourced all medical billing to an agency and estimates that he is saving around $75,000 annually.

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