Your Future as a Biller


By Rick Collins

As I near my 14th year of renal billing I can safely say I have learned one thing: our jobs never get boring! The unique regulations that apply to our industry continue to generate confusion across the country, especially with commercial payers. Plus, the ongoing changes to our billing rules require us to be continually learning.

The ongoing changes keep this column fresh and I appreciate those of you who read each month and send questions. This month we are going to examine a concern that improvements in automation will make billers obsolete in the near future. I will also examine how to deal with Reason Code 39012, payments to people in the United States illegally, adjustments for outlier payments made during 2012, and the option to submit medical records electronically.


As the number of electronic medical records (EMRs) continue to proliferate, some EMR sales representatives claim that organizations which use their software can greatly decrease or eliminate billing personnel. The rationale behind this claim is that an EMR with a billing module can automatically capture all of the data in the clinical portion of the software. The applicable clinical data is “seamlessly” entered into claim data fields and transmitted electronically with little or no effort on the part of billers.

Of course, saving money on labor sounds enticing to owners and managers. However, whatever labor savings may be realized can be quickly offset due to missed charges and billing errors. EMR vendors are quick to point out that checks are built into their systems that look for missing data and “scrub” claim data in order to prevent errors.

However, while an efficient EMR can be a valuable time-saving tool, I have never come across one that is infallible. To be fair, I have also never seen a biller that is infallible. However, a trained biller working with an efficient EMR can make a dynamic team that can result in a maximization of revenues and minimization of errors.

The big temptation with automation is to let the software handle all of the work related to charge capture and entry as well as payment posting. Billers as well as managers fall into this trap as they become so dependent upon their software that they fail to review data carefully. Further, their ability to review the data effectively becomes lessened because they do not keep up with ongoing changes in regulations that affect not only Medicare, but also Medicaid and commercial payers.

Another problem with automation is that customers of EMR companies sometimes demand modifications to their software that cause incorrect or missing data. To accommodate their clients, the EMR companies make the changes without them or the client realizing the change will result in missing or incorrect billing data.

Some providers rely completely on their software vendor to stay current on billing regulations and modify their billing software or module accordingly. However, relying on software vendors does not relieve the provider of their responsibility to file correct claims. The provider may also miss out on uncaptured revenues because they are not knowledgeable enough to recognize missed opportunities.

Over the past few years I have been contacted by providers that have lost significant amounts of money due to programming errors on the part of their software vendor. While software vendors try their best to reduce and eliminate errors, they are at the mercy of clients who demand customizations that may affect billing.

Of course, generating claim data and filing claims are only one part of the billing cycle. Checking the status of unpaid claims, following up quickly and promptly on rejected or improperly paid claims, and filing appeals as needed are also critical parts of the billing cycle. These processes are also becoming automated and while they may resolve simple issues, they are unable to deal with problems that require personal involvement.

For example, I continue to be amazed at the number of times our billing staff has to provide training to a payer on how to pay a renal claim. Our staff members are prepared with copies of regulations, examples and prior experiences with the payer.

Unskilled or unmotivated billers often refile claims or file appeals when they have not gotten to the bottom of the problems that caused the denials. For instance, when our company took over the billing for a provider, we found that the previous billers were simply refiling claims without correcting the errors that caused the claims to reject. Thus, when the provider asked her billers why claims were unpaid, the billers replied, “Oh, I refiled them.”

Of course, over time this practice caught up to them and the provider hired our company and we were able to immediately increase her revenues.

Filing appeals mindlessly is also an exercise in futility. Software can be programmed to file appeals automatically, but it cannot conduct the thorough investigations often needed to be done by people to get to the real problems that caused a claim to deny.

If billers are hired in-house, they must be required to keep up with changes in regulations and must carefully review claims data before the claims are submitted. If billing services are outsourced, providers should make sure the billing vendor carefully reviews claim data and has a program to continually train and update billers on changes in regulations. In-house or outsourced billers must also aggressively pursue unpaid claims and work with the payer to resolve problems before refiling claims or filing appeals.

Thus, billers who stay informed, carefully review data, and aggressively pursue unpaid claims will continue to be a valuable part of renal organizations going forward. Billers who are careless, uninformed, and rely on automation will soon find themselves replaced by the automation upon which they so heavily relied.

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