The Outsourced Medical Billing Network Effect And The CNS For The Chiropractic Office

Dr. John looked at the computer screen and felt nauseated: only half of the claims that he submitted for payment three months ago were paid. At two AM, Dr. John sat wide awake worried about what went wrong with his billing and about the future of his chiropractic office. Yesterday Pat, his billing assistant, seemed especially upset. Dr. John tried to remember her smile. She knew everything there is to know about billing when she arrived at his office doorstep three years ago. He caught himself thinking that Pat's moods were even less predictable than his wife's.

Was he wise to open an office? Why is he unable to get paid in full for his work? His revenues have not changed in the past two years, yet it looks like he will finish this year lower than last year. That's assuming he doesn't get audited. Though Dr. John couldn't recall any of the audit statistics recited by the speaker at the Association's presentation, he clearly remembered that the trend looked ominous; the likelihood of being audited seemed to match the likelihood of being involved in a car accident. Yet no insurance company covers audit risk...Is it because you always end up paying back when audited?

Dr. John thought again about the striking similarities of the information processing mechanisms between the chiropractic office and the human organism. Both the human body and the chiropractic office are complex information systems, where the flow of information must be uninhibited in order to have them growing at a healthy pace. The office, just like the human body, must perform its vital functions optimally to grow and to avoid risks.

In the "human body-chiropractic office" analogy, the CNS is not just the software that facilitates such functions or the office staff that performs these functions using the software, and it's not just the procedures that the office staff follows when performing these functions using the software. The CNS concept unites all three components of information flow management, including procedures, technology, and staff who follow the procedures and use the technology that results in the desired behavior. The CNS is:

* Comprehensive - The CNS covers every aspect of a physician's practice, starting with patient scheduling, registration, documentation, and billing.
* Timely - The CNS responds in real time: collections are updated as they arrive, coding advice is dispatched at the time of SOAP note entry, the patient is questioned about outstanding balance at the time of appointment registration, the compliance with care plan is reviewed at the time of the doctor's appointment, and questions between billing and front office personnel are resolved online.
* Intelligent - The CNS synthesizes new information from available data to make suggestions to the physician about potential audit exposure due to over-coding or about potential applicability of a treatment or a vitamin because another patient with similar history used it and received positive results.
* Self-Improving - The CNS shares practice management and billing knowledge across all the providers on the entire network. Every new chiropractor that joins the network, benefits from all others that already joined before. So the value that the office receives from being a part of the network keeps growing with each additional office. Such an expanding community-driven effect has been documented by amazon.com, yahoo, and flickr and it's called "network effect."
* Accountable - The CNS has built-in "memory" that keeps tabs of every claim and of every action on it so that the entire billing process is tracked: form coding to claim submission, payment posting to follow-up.
* Transparent - The CNS has a built-in continuous measurement process, collecting and communicating information about patients waiting, payments paid, etc.
* Proactive - The CNS generates symptoms and directions automatically and independently of the staff. It discovers underpayments and delays or patients that left the office without billing and alerts the front-office staff about problems.
* Intuitive - The CNS generates simple and easy to understand signals that require simple decisions, such as "correct the ICD-9," or "call the insurance company," or "request patient demographics."
* HIPAA-compliant - The CNS delivers the information on the "need to know" basis only.
* Universal - The CNS provides every participant in the billing process, including patient, provider, payer, and biller, with access to every aspect of the billing process.
* Continuous - The CNS makes process detail available continuously on a 24 x 7 basis.
* Ubiquitous - The CNS provides access to billing process over a secure standard Internet browser that requires no special hardware or software and is available everywhere.
* Scalable - The CNS makes both the big picture and minute detail 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 a comprehensive summary of patient visits and unpaid balances. The minute detail pertains to individual claims making up the big picture, including a 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 for an arbitrary aggregation of claims and drill in detail to enable effective follow-up.