I have been in the Medical Billing Industry for 20 Years and had my business for 12.5 Years. In August 2016, I made a decision to close this line of service to my customers out by 12.31.2016. When you have spent you complete career learning the industry inside and out, this was a very tough decision to make, but at the same time, I felt deep within my heart that it was the next move in my transformation journey.
I would like to share with you why.
In 20 Years, the Medical Billing Industry has become way more complicated then when I first started in it in California. The industry is no longer just billing out the service at the appropriate level for the procedure codes performed along with the diagnosis of the patients condition. It is more dynamic than that. It has become political and games along with a deeper fight to make money at. They target larger practices and disregard the smaller ones.
The success in Medical Billing comes from how well you know the rules, both on a State and Federal level. The ultimate success comes on how willing you are to fight when they are wrong, when they don't pay per contract, when they bundle things together that should be paid separately, when they deny the claims stating that the medical records do not support medical necessity for the services performed, leaving you with no option but to then have to appeal these denials or incorrectly paid claims - up to three times through three tiers. Insurance companies can and will recoup money (this means take money back) for whatever reason stating they paid these claims in error. You then have to fight to prove them wrong, sometimes even having to get the Texas Department of Insurance or Texas Medical Association or Health and Human Services Commission involved.
You go through annual chart audits to ensure your documentation is meeting all the requirements. You are rated on protocols, policies and your compliance. You are rated on how many children you give vaccines to and if you have given them at the time they are due or if you give them late. You go through intense documentation reviews, coding reviews, and board reviews. The results is that the industry simply is a never ending battle to just to get paid for services your client/the physician has already rendered to the patient.
It is ironic to me that no other industry works like this. If you want groceries, you have to pay for them at the time of service. If you want fuel, you have to pay to fill up your tank. If you want clothes, you have to pay right then for them. You do not get to get all the groceries, fuel or clothes you want and then file a claim to insurance to see if they will pay for it. Even deeper than that, since the Pharmaceutical Industry doesn't work this way, you know at the time you pick up your prescription what you will owe, why can't medical claims be adjudicated in the same manner? There is no reason it can't, it simple is a tactic to stall making payments and to give insurance companies an out to make money by denying services.
A successful Medical Billing Agency will have a high percentage of overturned claims. Nearly all Medical Billing Agencies make a percentage of collections. Therefore this means if a client/physician isn't being paid, neither are they. If an Insurance Company decides to recoup on previously paid claims, money is taken back from them too. If a physician is going through an audit, this burden will be born by the Medical Billing Agency on top of the daily routine. This makes the work simply an every day fight. Literally. Every day is a full blown fight. And you never know when an insurance company will decide to take back $26k or $57k just like that, in one fell swoop. You will spend your days arguing with Customer Service Representatives that have not been trained on the State and Federal Laws and honestly do not care to learn them, they are simply punching the clock and their goal is to simply answer the phone and get you off as quickly as possible, even if that means hanging up on you if they do not want to help you. Some Insurance Companies like Medicare and Blue Cross Blue Shield have a limit on how many claims they will help you with per a call and they make you call back and go through the long hold times, like anywhere from 15 minutes to 3 hours, to get to talk to a representative. Once you get someone one the phone, in order to get anywhere you have to be willing to argue and fight over every little detail or you won't make any money.
As you an imagine, it is emotionally draining and mentally exhausting. And I have done this for 20 Years. And I became extremely good at it, not just because of some personality traits or experience of fighting for my life through my whole childhood, but because I put in the effort to learn all the State and Federal Laws to help me be good at it, and I gave every single claim the same attention every single day. Producing results that many of my employers and clients had never seen.
But it got to a point that I wanted something more for my life. I felt there had to be a better way to work in the industry. Thus began my work with Mentors and Coaches the last 3 years to reframe my mental thinking and attachment to my work. I have worked to change my perspective in the fight. I have made efforts to shift my process in the fight. I have created set work hours to not be a workaholic, to drive my business from a vision and not from an emotional work load perspective, creating work life balance that I should have had a long time ago. I have created more vacations and time off to unplug from the stress to be able to allow me to be more upon my return to work. I have fired clients that didn't want to abide by the State and Federal Rules and Regulations. I have stuck to the terms in my contract and if a client doesn't pay me on time, they are assessed the late fee. If they still do not bring their account current, there is no work done until they do. If I was an employee in their office they would have to pay me on the date they have set with the Texas Workforce Commission, why should this be any different just because I am a Vendor? It shouldn't. I have grown to honor and respect me and set boundaries to respect myself and my work. I have hired better team members, ones that have a vision and personal purpose to live in alignment with the goals and vision I have for how we work with our clients.
Yet...at my core I am exhausted of the fight to make a living like this and believe that God has more for me. In my quest to create a more simplistic lifestyle on all levels, this isn't in alignment with that. So, even though this decision impacts revenue and production, and is a loss of 70% (or more some months), I had peace in choosing this because I will settle for more! Exactly where this will take my business now, I obviously do not have the full answer for, but I can promise you this, I know that God will provide the answers and take care of just like he has through every other difficult decision or challenge or traumatic event like audits, lawsuits, and long periods of not being paid.
I will stay focused on my core beliefs, the vision I have for my life and business and the impact I want to make in one persons life each day. Here is to another New Chapter in my life!
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