Medical Billing Transparency 

Medical billing industry has volumes of arcane terminology and payer- and time-dependent claim validity and pricing interpretation rules, facilitating massive payments of invalid or ineligible claims and denials of error-free claims. Process transparency provides its participants greater visibility of internal process activities. An increased level of access promotes teamwork, increases client satisfaction, and assists in process streamlining.

Billing process is the interaction between the participants (i.e., insurance company (payer), healthcare service provider (provider or doctor), patient, and billing service provider (biller)) designed to pay or deny a payment request (claim) submitted by the biller to the payer and to the patient on behalf of the provider. The amount and complexity of billing information make it very difficult for the doctor to maintain compliance and identify and resolve errors and underpayments.

Billing service transparency allows participants of the billing process to expedite error identification and resolution, resulting in reduced over- and under-payments and improved regulatory compliance.

Attributes of Billing Transparency

Billing transparency has four key attributes, including universality, continuity, ubiquity, and scalability.

• Universality: every participant in the billing process, including patient, provider, payer, and biller, has access to every aspect of the billing process.
• Continuity: process detail is available continuously on a 24 x 7 basis.
• Ubiquity: access to billing process is provided over secure standard Internet browser that requires no special hardware or software and is available everywhere.
• Scalability: both the big picture and minute detail are available for scrutiny universally and continuously. The big picture consists of total cash flow in a given time period, current submitted and failed claims, and billing quality metric. It must contain comprehensive summary of patient visits and unpaid balances. The minute detail pertains to individual claims making up the big picture, including complete history from the moment of creating the claim, testing its validity and eligibility, making corrections, performing submissions, reconciling payer messages and explanations of benefits (EOB) with original claims, until payment. Both perspectives must allow arbitrary aggregation of claims and drill in for detail to enable effective followup.

How to Build Transparency Into Your Billing Service?

A transparent billing service leverages technology to enable competent personnel to execute disciplined billing process. Therefore, to implement a transparent billing process, you must

[ ] Get access to adequate technology to support universality, continuity, ubiquity, and scalability.

[ ] Develop and thoroughly document claim processing procedures, including compliance and integration with practice workflow.

[ ] Train personnel in following the procedures and using the technology

[ ] Review personally and continuously billing quality, technology capabilities, adequacy of procedures, discipline, and training.

Note that Vericle-like technologies based on Straight Through Billing (STB) methodology implement billing transparency by design because billing transparency is an integral attribute of every component of STB process.