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Promises and the Art of Not Keeping Them

in  billing    medical billing    rcm    claims  

“If it sounds too good to be true, it probably is.”  - Unknown

“Here's the way I see it, Ted.  Guy puts a fancy guarantee on a box 'cause he wants you to feel all warm and toasty inside.”  -Tommy Callahan

There’s a story about a guy who dies and is given a choice between eternity in either Heaven or Hell.  Saint Peter even gives him a sneak peek at each before he has to make up his mind.  On his trip to Hell the elevator doors open to a party by the pool, complete with volley ball, pretty girls in bikinis, wait staff, and drinks with colorful little umbrellas.  He has a great time. 

When he gets to Heaven he has a relaxing day visiting lost friends and relatives.  He attends chapel, and even takes part in a group harp lesson.  At the end of the tour he meets Peter at the gate.  “To be honest, you have a nice place here, he mutters to Peter, but by the end I was kind of bored.  He enthusiastically picks Hell and steps into the elevator. 

When the doors open there’s no party today.  Flames reach to him from every direction.  Smoke scrapes his throat and stings his eyes.  One of the wait staff from the party now walks on cloven feet and horns grow from his forehead.  The devil grabs the guy by the neck and drags him across burning coals to the eternal registration desk.

“What the Hell?” the bewildered guy protests.  Where’s the party?  Where’s the pool?  The drinks?

“Oh,” replies the demon.  “That was our open house.”

You’ve seen them - websites or direct mail from billing companies making unrealistic claims (no pun intended) about what they can do for your revenue cycle.  The promises seem valid enough.  Assurances range from revenue increases to fairytale KPIs to 100% electronic claims submission - and come with more stipulations and qualifiers than a prenuptial agreement.  These kinds of promises are always based on certain assumptions that make achieving their ambitious goals easy and, well, not-so-ambitious.  Let’s look at three…

All claims are filed electronically.  The assertion that all of your claims will be filed electronically suggests that all payors to which you submit a claim will receive that claim in an industry-standard electronic format. 

Not so fast.  The promise refers only to the method by which claims leave their building.  No electronic claims clearinghouse submits directly to all payors, so claims are often forwarded to other clearinghouses for submission, or dropped to paper.  Technically speaking, the vendor has kept his promise, but in reality not so much.

An exceptionally (unrealistically) high first pass adjudication rate.  This guaranteed stat is often based only on those claims considered “clean,” and likely discounts charge information containing data inaccuracies or coding issues.  Failure to achieve unrealistic first pass rates will likely be deemed the provider’s fault.

100% of claims will be filed within 48 hours of receiving charge information.  The asterisk next to this promise should say, “Charge information means full, complete, and accurate data, and does not apply to any documentation requiring clarification or correction of erroneous information that may have been initially supplied.  Oh, and by the way, does not include weekends or holidays.”  Getting clean claims filed within 48 hours of receipt of full and complete charge information should go without saying and is no great feat. 

The point is to be careful of RCM vendors making statistical promises.  Know exactly what is being guaranteed before signing a contractual agreement.  The best promise is a track record of success and a long list of satisfied customers.

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Cvikota Medical Business Services is also affiliated with Cvikota EMS Ambulance Billing Professionals. Cvikota MBS serves clients nation-wide, with offices in Wisconsin and Tennessee.

Cvikota Medical Business Services
2031 32nd Street South
La Crosse, Wisconsin, 54601 USA
800-657-5175 · fx: 608-788-6613
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