Monday, April 05, 2004

The Reality of Outsourcing in the Hospital Industry

Authored by Karen Erkkila

I want you people to listen up or should I say read up! This will effect most YOU at one point or another. When a hospital business office is outsourced where do you think you are going to go to get your medical claims resolved? The company that outsourced the business? Ha, ha, ha. Not so they are out of town. Ha, ha, ha. Does anyone know what it takes to get a claim paid? Guess what, hospitals and doctors do not have to bill your insurance or have any contract with your insurance that allows so much of your account to be adjusted off. The UCR. This is a courtesy. Once there are no contracts between hospitals and doctors you will be responsible for what ever your insurance does not pay no matter who you have insurance with and YOU will be responsible for filing your own claims and for the total bills due.
Hospitals file claims for a number of reasons one of which is a service to the customer and the other is because they are better prepared to run the gauntlet that getting an insurance premium paid.
A business office consists of 3 to 4 groups. Claims, billing, customer service and collections. In a medium sized hospital of 300 beds or so it takes 30 to 35 people to take care of claims and the resulting customer responses.

First when you come to a hospital you have to go thru registration, so that your insurance and personal information can be entered into the computer for insurance filing and billing. Then once you have test, labs, x-rays, outpatient surgery, surgery or hospital stays the hospital has the info needed to file your claim. Before a claim can be filed it has to go to medical records where the diagnosis and charge codes are put in along with the type of bill,ie hospital surgery, outpatient surgery, lab, xray and hospital stays, revenue codes and occurrence codes. These codes are used for the insurance company to determine what kind of service was done, when, where and why and from there determine proper payments .
Do you know what a revenue code is? Do you know what an occurrence code is? do you know what a HCPC is? A CPT-4 code or an ICD-9 code is? Do you know what an meob, eob or cob is? All used identify and create your bill to send to your insurance company

Primary insurance is the insurance that you have that pays for your lab work, out patient surgery, surgery, hospital stays and x-rays. Any medications that you need and any supplies used during this time of the visit. That is why we need a copy of your insurance card. Now a secondary insurance is an insurance policy if both spouses work and the husband has insurance on him and his wife and the wife works and has insurance on her and her husband. For the husband his insurance would be primary and the insurance his wife has taken out on him would be secondary. and the wife's insurance would be primary for her and the insurance her husband took out would be secondary. Some people have Medicare when they retire and that would be primary and if they keep the insurance thru their employer this insurance would be secondary and then there can be third and fourth insurance's.
All of these things are needed to file a claim. I would say that on average 40 to 45% of all claims have errors or problems with the insurance information that needs to be corrected. The insurance companies have to have the proper codes for what you are being billed for these are the CPT or ICD 9 and the proper diagnosis codes the for the claim which are the CPT-4 codes. If there is secondary insurance we have to have the meob, eob or cob. This stands for Medicare explanation of benefits, explanation of benefits and coordination of benefits.

There are a lot of positives to having a business office avilable in the facility where you recieve cares.
A lot of claims are sent electronically to your insurance company which means if there is an error the claim will kick out; in other words the insurance company receives the claim reviews it and if there is an error that info is given to the hospital within a week for correction.
Claims department makes sure your claim gets to your insurance company with all the proper coding and codes. Sometimes when you register, a mistake is made. Then it goes to billing and customer service. There any problem is found or the patient is called or sent a letter telling them to contact the hospital so the claim can be processed and paid for the patient. Billing and customer service are the interface between and their insurance companies and most hospitals you can walk into and ask for help with claims or billing. Most Customer Service Representatives are hardworking and honest people that will go the extra mile to help you.

Now if do not respond to calls or letters your account will go to collections. Usually by then the patient will call and give us the correct information we need and the claim is refiled. If not then the patient is responsible for that bill because we only have 90 to 180 days to get your claim filed. We even have charity or indigent care for those patients who cannot afford to pay the balance on their claims. collections and customer service are also tasked with helping patients with this.

All of these services are performed by the hospital business office and representatives have at there disposal in a hospital all of the resouces close at hand . If the insurance company needs a file the CSR's can run down the hall and get it from records and fax it. Any clerical errors are easily corrected. We also have to remember that these same office workers work in the cities and communities of the hospitals.. They have a vested interest in seeing these hospitals flourish. Outsourcing almost always takes the business office out of town. The people who would have interfaced directly with the insurance company, customers, and hospital are invariably moved to other positions in the hospital or laid off. Bad for the local community. Good for the gobal economy but I don't think that the people who are laid off or the local community at large are served.

If this business office is outsourced where are you going to go to get your claim paid correctly? The new outsourced billing company? They couldn't care less they do not have access to your files and it could take weeks or months for them to get back to you. Remember you only have 90 to 180 days to get your claim filed. Happy trails trying to say to the hospital that they didn't file your claim properly because they don't have to do it for you . Is this what America wants? Is this what YOU want? Just think if hospitals can do it so can everyone else. . And by the way, usually when an office is outsourced it goes to another state completely. Gonna call or go to Tennessee or California to get results, it will not happen.

I have worked for hospitals who have outsourced their billing and 6 months to a year later they get their claims back in hundreds of boxes that these companies cannot get paid because they didn't care to work at it . So I don't know about you, but I would rather have someone who knows what they are doing and can help me right here and right now. And I do not want to be stuck with a bill just because that outsourced billing company has no idea of what they are doing. And how about those automated telephone systems. There great aren't they until the problem you have doesn't fall under the category you need help with.Sure it is ok for small doctors offices who cannot afford the software or the people to do the billing, but let's look at the big picture, no one there at the hospital to help you, what are you going to do? You are stuck with the bill. So let's keep outsourcing for the smaller companies or doctor offices and let's keep the hardworking and honest people there in that hospital or large company to help you when and where you want it.

One other thing. How do I know all these things happen? You should have seen the mess that a local hospital billing was in after their foray into outsourcing. They lost millions, Millions. They almost went under. It took two years to get the hospital back in the black.

Well anyway Good luck if your hospital outsources. Hope you don't get stuck with your bill. Ha, ha, ha, ha.

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