Finding a top medical billing service can be extremely difficult.  Some practices go through many billing companies before finding one that meets their needs and delivers excellent financial performance.

Referrals from EMR Vendors

So how do you go about finding an outsourced revenue cycle management company that is not only experienced in neurosurgery but delivers great financial results and excellent service?  Some practices get referrals from their software vendors like the practice management software (PMS) or electronic medical records (EMR) / electronic health records (EHR) company.  While this seems like a good way to find a reputable medical billing service, following is the cautionary tale of a neurosurgery practice who had originally found a billing company that way and it was not successful.


The EMR was a large well-known national software company and referred them to a neurosurgery billing company that used their software.  The neurosurgery group was starting the practice from scratch and made the reasonable assumption that even if it was not a top neurosurgery billing service, it was at least good and would perform well for them.  The medical biller (I use this term rather than neurosurgery billing company because it is not entirely clear whether there was anyone else other than one person in the organization) struggled for many months as no revenue came in for the practice.  It turns out the biller wasn’t experienced in neurosurgery billing and had no knowledge of neurosurgery coding, modifiers, payer rules, or any other aspect of neurosurgery coding and billing.  They were essentially frantically trying to learn on the job.


Neurosurgery happens to be one of the most complex specialties for coding and billing, and so there is no way to learn on the job fast enough.  Just because a billing company is good at one specialty does not mean they will be good at another and neurosurgery billing is one of the most challenging.


Knowing Billing

One needs to be careful of referrals from an EMR company.  While we might think that concern for the reputation of the EMR software company would ensure they refer you to someone that will be perform well, but that is often not the case.  The first problem is that EMR software vendors are not experts in neurosurgery billing or any medical billing for that matter.  Boeing may know how to build airplanes, but they do not know how to run an airline, which is a completely different business and set of skills.  Similarly, even if the company knows how to make good software, that does not mean they know how to identify and select a good physician billing service.

More importantly, most electronic health records software companies do not focus on the billing module of their system.  Most neurosurgery practices choose the EHR based on the clinical workflow (EMR) and may only review briefly (if at all) the billing part of the practice management system.  Since the choice in EMR is almost always driven by the clinical part, the vendors know this and invest heavily in that module, while often neglecting the billing system.  This means that most EMRs do not have particularly strong capability when it comes to medical billing.


Incentives Not Aligned

An even greater issue in this case is that the alignment of incentives is wrong.  If the best neurosurgery billing service (or orthopedic billing service or whatever your specialty is) doesn’t use their software for billing, they will not refer you to them even if it would mean much greater success for you.  Their referral won’t be to whoever they think is top neurosurgery billing company in the country, but will refer you to a company that uses their software.  It would look bad if they recommended someone that uses someone else’s software, so they are kind of trapped unless they are lucky enough to have the top neurosurgery billing company as a client.  Odds of that are not high since there are hundreds of PMS systems out there, so odds are perhaps 1% at best.


Spine coding is extremely complex, and the entire revenue cycle management (RCM) process is very difficult for neurosurgery, with lots of denials, many complex payer rules, tons of requests for documentation, and medical necessity verification.  Appeals and resolving unpaid claims is really challenging due to the complexity, and requires knowledge of neurosurgery and spine coding on the back end, as well.



In words of the neurosurgery practice, “All the claims were denied in the first few months.”  This meant nothing was getting paid.  The practice started running into financial trouble.  The biller was so overwhelmed that many patient encounters were never even billed out.  Five months after the submission of the Medicaid enrollment, the practice was still not yet enrolled.  Eventually the billing company quit because it was so overwhelmed.


Don’t They Need to Know My EMR Software?

NO. Your success is not predicated upon them knowing your EMR and PMS software. A good billing service can interface to your EMR in order to extract data or have other means to obtain the data they need in order to bill.  This can include sFTP or other methods.  You should be able to keep your EMR for clinical workflow and the PMS for your front desk regardless of what billing company you select.  Any flexible company will not force you to change in order to meet their needs and it will not impact on your financial results.


Selecting a New Billing Company

In order to ensure the neurosurgery billing service you are selecting is capable, request they code a number of spine procedures and evaluate their performance.  Find out how they keep their coders educated on changes in neurosurgery coding.  Ask for their feedback on your operative reports and see if they have suggestions on documentation. Most importantly, you should perform a complex analysis comparing your results to theirs making sure to match and adjust by procedure, payer, plan type, modifiers, fee schedules, contracted rates, and more.  You can either do this yourself or engage a company like Apache Health to do it for you


All Specialties Are Not Created Equal

We see this often where a billing company may do well billing for internal medicine, general practitioners, and other less difficult specialties, and then they get referrals to other specialties that they are not experienced with and it goes badly.  Usually the neurosurgeon or other provider fires the underperforming billing company and then a true neurosurgery billing company comes in and cleans up the mess.  Most of the major problems can be remedied within a few months, although the practice has lost a significant amount of revenue and cash flow has been delayed tremendously.  If the neurorugery practice does not have deep pockets, it might not survive during this period.  It is much easier to do things correctly the first time than to clean up the problems after the fact.  Some revenue can never be recovered since timely filing limits are an issue for both claims submission and appeals of denials.


All this can be avoided by going initially with a physician billing service that specializes in your field and has a wide breadth of clients in your specialty (for example some are more experienced with workers comp, while others with Medicare or personal injury).


Pick Independently

The moral of the story is, pick the EMR that you like the best for your clinical workflow, but don’t assume they can refer you to a good neurosurgery billing service or whatever your specialty is.  Find them independently.  Research for top “neurosurgery billing company”.  Check the neurosurgical scientific conferences for billing services.  If you get a referral, test their knowledge by giving them charts to code, especially complex spine cases.  And vet them thoroughly.  The more time you spend asking questions, the more likely you are to choose the right billing company.


About Apache Health

Apache Health is a revenue cycle management (RCM) analytics, benchmarking, and auditing company. The founders of Apache formerly ran a large RCM company that was acquired by a private equity group in a rollup. Apache’s predictive analytics will benchmark billing performance and project exactly how much more revenue you should earn from your existing volume of patients.  Using many factors and a blend of artificial intelligence and specialty specific benchmarks, the model projects whether changing the billing process would improve collections for your particular mix of procedures and payers. Apache Health can help you evaluate whether to outsource the billing, determine which billing company to select to maximize performance, or track in-house billing performance improvement over time. For more information contact:

 Sean McSweeney

Apache Health


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