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I’m going to share with you today one of the inherent challenges, I think, in billing. This applies whether or not you’re a billing company or an in-house billing group, and that comes down to sort of the finger-pointing and blame game kind of issue. Effectively, how do you figure out responsibility? Where did something go wrong, and why?

Remote working

From a billing company’s standpoint, this is something you constantly manage. I think it’s amplified and made a little bit worse. In addition, we certainly experienced this because you’re an outside organization. You’re not down the hall. They can’t see you all day, every day. 

Even though you’re in constant communication at multiple levels with them, it still doesn’t mean that they have the same relationship with you as they do with somebody in the office. Maybe, it’s even in a separate building, but somewhere they can walk to.

I think human nature is such that it’s always easier to blame somebody else than to blame ourselves. So clients typically blamed us even if it wasn’t our fault. Of course, sometimes it was our fault. Indeed, we did screw things up. We’re human.

How do you pinpoint the culprit?

I think that one of the fundamental challenges is several things embedded in that one, “How do you even figure out if you are responsible?” I mean, like, did billing screw it up, whether it’s again a billing department or a billing company, it doesn’t matter? Did you screw it up, or was it something else? Was it outside of your control? It was not your responsibility.

Indeed, insurance companies are constantly trying to screw you. Some problems come up. They create those problems frequently intentionally. What do you do? Of course, you want to run a good billing department or run a good billing company. In some ways, you’re condemned if you do and damned if you don’t.

If there are problems and somebody comes to billing and says, “Hey! You screwed this up.” If you take responsibility for something that you didn’t do or that you don’t even know whether or not you or your team was responsible for, you’re going to get fired. You can’t do that very often. The first time, you would say, “Hey! Well, great!” You took responsibility. The second time, you’re on a shortlist to be fired if you’re not already fired.

If you see it’s not your fault, you’re also screwed. I guess it sounds defensive. Even if it isn’t your fault. Indeed, if there’s a pattern of situations that come up where there are problems, and they’re not your responsibility, and you say so. Somebody thinks it is your fault. It seems like you’re just a serial denier, and you’re not willing to take responsibility. You’re damned if you do and damned if you don’t.

Who’s to blame?

A bigger problem is, “How do you even know if it’s your fault?” I mean, how do you get to the root cause of that? How do you figure something out? You can ask somebody in the department and say, “Hey, what did you do?” or “Show me the information” or that kind of stuff and dig in, but that’s very complex.

Let’s say, for example, an insurance company screwed something up: 500 claims didn’t get paid. Maybe. I’m going to make something up. Perhaps, they said they didn’t get some documentation, or they said there was an enrollment issue or whatever it might be, even though you sent in the documentation to update or whatever it might be. 

For all appearances, to anybody, it looks like the billing screwed up, like, “Hey! You didn’t update or didn’t keep enrollment or registration information current, and therefore a larger number of claims didn’t get paid.” The responsibility looks like it’s yours, so it’s kind of like you’re assumed guilty until proven innocent rather than the opposite.

Most managers, whether it be a physician or an executive in a provider organization. We will naturally believe, even if it’s not 100% of the time, that the insurance company is essentially telling the truth even though we know insurance companies screw people constantly, and they screw up constantly.

Is it the insurance company?

Then, there are much more complex and even nuanced problems. Let’s say, for example, massive amounts of claims are showing that they’re not getting paid by insurance companies. It says, “The wrong insurance company.” Well, was that because billing sent them to the wrong insurance, mixed, switched primary and secondary, or just sent it to this Blue Shield instead of that Blue Shield?

There are 50 different Blue Shields if you pick somewhere in Colorado or something like that. You’ve got to send it to the correct location and select it in the system to have a valid address. Otherwise, even though it went to the right company, they deny it and say, “It’s not on file” because you didn’t have the correct information.

Is the data correct?

Was that a problem that billing had? Or was it that somebody passed the wrong information to billing? When they entered the insurance information, they swapped primary and secondary patient registration at the front desk? Or was it that checking eligibility at the front desk didn’t actually happen or was done incorrectly? 

Therefore, the wrong information is provided to billing. Billing sent it to what was on file, and that information was incorrect. How do you assign responsibility to that? Or let’s say it was terminated or something like that, and eligibility was checked at the wrong time. How do you figure out the responsibility, and how do you take responsibility for the things that are accurately your mistake and not for the others?

From a billing company’s standpoint, this is complex. You could alternatively find sort of a similar problem in terms of in-house politics. Suppose you’re a billing company and, let’s say, for example. In that case, there’s the problem of that eligibility we’ve talked about, eligibility either isn’t being done, or it’s being done poorly. 

Are the claims routed to the right places?

Further, a very high percentage of claims are going to the wrong place, and therefore, you’re getting a ton of denials and claims not getting paid and all kinds of stuff. It’s not easy to go back and find the patient later to get that information. So stuff is being written off.

If you’re the billing company and you’ve got a client screaming at you and saying, “Hey! You’re screwing this up, screwing this up,” and you say, “Hey! Your front desk sucks,” that’s not going to go super well. Indeed, if you don’t have much data to back that up, how do you do that?

Again now, in that kind of “you’re damned if you do and damned if you don’t” situation, if you do all the eligibility work for them, you’re not going to get paid for it, and you’re not going to get credit for it either, so it’s a lose-lose. You would clean up the back-end problem by doing a bunch of extra work, not get paid for it, and not get credit for it because they would think, “Well, you just solved the problem that you had already created.” 

So you’re cleaning up your mess. If you don’t, well, then you still keep getting tons of denials, and maybe the clients are yelling at you, all that kind of stuff. How do you get yourself out of that situation? That’s a real challenge.

In conclusion

In terms of whether you’re an in-house billing group, you effectively can have the same problem because, in many organizations, that front desk patient registration or something like that may be in a different group or another part of the organization or something like that or in the other manager than is billing. You have in-house politics to deal with, which is you’re throwing a rock at somebody else in the organization. They’re not going to want to hear that they’re screwing something up or that their people are screwing something up. That’s the real challenge.

Tune in on the next episode! We’ll talk about some solutions to that.