Training Primer - What do I charge?

[Danni R.]

Yes, Steve, we DO get that question all the time. Thank you very, very much. Whether it is a repeat (duplicate post) or not. You cannot say it often enough.

[Steve Verno]

I dont know if I posted this, if not, here it is, if so, here it is again.

A question a new biller asks when working to get a provider to use their services, is, What do I charge? 
There can be many answers.
Flat Fee
Percentage

Flat Fee:
This is a set amount that some charge on a per claim basis or a per statement basis or both.  What amount is fair?  That can differ per specialty, and per geographical area.  For example, A biller in New York City, working for a family practice provider may wish to make $X per claim and $Y per statement with a minimum of 2 statements per patient.  A biller in Clarksville, Iowa may charge less per claim or statement because the costs in Clarksville may be lower than the costs in New York City.  Also, a flat fee for a platic surgeon in Las Angeles may be different than a flat fee for a pediatrician in Ayer, Massachusetts.  You must take into consideration your expenses, the number of patients seen by the doctor, and how much work you put into getting a claim submitted and paid or submitted and denied/appealed.  Do you do one appeal of a denied or incorrectly paid claim, or do you set the limit to two appeals whether the appeal is won or not.  One must understand their goald when working for a provider.  Lets say you agree to send one appeal only with no follow up.  This may possibly jeopardize your future commitment with the doctor, especially when the doctor notices many denials and a huge reduction of current revenue.  You have to realize how much you are spending to get the doctor paid, especially when the doctor is not coding correctly or the administrative staff is not cooperative with providing you with info you need to accomplish your job.   You must also set your fee as accurate as possible because once ou and the doctor agree to a price, you dont want to go back to the doctor, 60 days later to say you need more money.  That could result in your needing more money because now you are out of work.  You also dont want to overprice yourself out of work. 

Percentage:
Percentage billing could be based on the amount of charges you submit or a percentage of monies you recoup or bring in.  If you base your percent on charges submitted, this could backfire because one must understand that the doctor is not going to get 100% of what you submit.  the doctor may understand this as well, knowing reimbursement is reduced based on Medicaid/Medicare/Workers Comp allowables and health insurance contracts.  The doctor could find that using you is losing him revenue and the best way to start making a living is to terminate you.  Percentage Billing may not be allowed by applicable State Laws or by State Medicaid.  If you code and bill, there may be some objection by your local Medicare because of the possibility to upcode visits as a means of increasing revenue.  How this works is, you charge 15% of what you recoup or bring in.  The visit may be a simple 99203, but you bill a 99204 or 99244. A 99203 may bring in $100 but a 99204 brings in $150 and a 99244 brings in $300.  The $100 would see you making $15.  The $150 would see you making $22.50 and the $300 would see you making $45.  Upcoding could open the provider to audits, fraud investigations or pended/reviwed claims or down the line, a refund demand of monies paid.  In addition to upcoding, percentage billing could lead to, "we billed XXXXX, ABC insurance denied it and we need to get it paid.  You need it paid because you get paid $X if XXXXX is paid. If denied you get nothing.  The denial may be valid and unappealable.  Like a flat fee, how much you establish is based on your work of what  your expenses are.  Charge too much, you lose your client, too less, you cant support yourself.  You need to be specific regarding your balance billing percentage and what it includes.  Some try to bill a percentage of just what is brought in by the biller, some try to bill a percentage of all money brought in and this includes money collected by the office staff in the form of copays or coinsurance.  Like a flat fee, one must take refunds into consideration. Lets say you recouped $100 on a statement sent by Mr. Magoo.  Mr. Magoo overpaid so he is due $50 back. If the patient or insurance company overpaid, the overpayment cannot be kept. It must be returned.  In reality you brought in $50, not $100. 

Setting up how much you charge is hard work.  You must always take your expenses into consideration.  Asking, "How much do I charge if I am in the Hooterville area?  You may not get any answer because Biller A may be in Hooterville and doesnt want to be undercut by you when you get to meet with the doctor, so you say, Most billers in this area charge 15%, you hire me, Ill charge you 10%.  Now, Biller A is out of work.  YOU find that 10% is too low and going back to the doctor to ask for more money is unwise.  The doctor looks at Biller A and you.  Biller A brought in $400,000 per month and yes, charged 15%.  You are bringing in $80,000, you have $300,000 in unpaid receivables, so is using you beneficial or is firing you and rehiring Biller A more financially beneficial?

You must also know your doctor, how many patients are being seen, how much is out going in charges, how much has not been recouped, how many denials are received on a monthly basis the variables such as Medicare, Medicaid, workers compensation, and contracted carrier patients.  While asking how much do I charge if I am in the Hooterville area may or may not have any answers provided.   The doctor may suggest how muc he/she is willing to pay you for your work.  YOU must make a decision as to whether to take that offer or not and that decision is a lonely one and one no one but you can make. 

How much do you charge is one of many complicated issues that are part of medical coding and billing.  It is a business decision you have to develop.  To decide you must take every factor into consideration.  Your expenses, the doctor and the factors that involve claims payments.  You must also understand that you are in competition with every other medical coder and medical biller in your area that you are competing with to get the doctor's business.  You need to be at the right place, at the right time, with the right qualifications and with the right price.  The door opens and closes quickly.  Once you get in, do the best job that you've been trained to do, earn the doctors trust and you could be with that same doctor for a long time.  The word may get out about you and that may open the door to many other opportunities.