Healthcare insurance is perhaps the most complex aspect of the American healthcare system. The right healthcare billing partner is essential to capture the most revenue a practice can. Most healthcare organizations operate on very limited margins, according to Becker’s even half of hospitals ended 2022 with negative margins. 

If you’re currently evaluating billing solutions, our partner Adonis.io recommends starting by asking yourself the following question: “Are you looking to outsource your billing or are you looking to augment your existing team or technology?”

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Starting from here can help you narrow down the types of solutions you're evaluating the potential cost and ROI associated with each.

Common Types of Billing Partners:

A Clearinghouse - If you’re just looking for a way to submit claims to payers, an insurance clearinghouse is the way to go. Clearinghouses typically get involved in other common areas of insurance like eligibility checks.

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An RCM Platform - An RCM partner can mean a couple of things but for the purposes of this article, we’re going to talk about it in terms of technology and services. An RCM platform is a great way to get a more holistic view of your organization’s billing. RCM platforms may give you insights on denials, and help you collect any patient responsibility. 

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An End-to-End Billing Partner - Some organizations may need billing expertise, technology, and services for their entire revenue cycle management function. Companies that offer end-to-end billing services typically combine technology and services to take on the tasks an in-house billing team would normally do after receiving a denial.

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Point Solutions - Maybe you like your clearinghouse or RCM platform but need an additional solution to do just one thing like eligibility checks. Point solutions typically offer technology to handle one or two items.

What do billing solutions cost?

Depending on the solution, there are a couple of common pricing models. But as our partner Candid Health shares, it’s important to find a company who is willing to partner with you. Here’s what they said: 

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“Pricing for billing platforms can vary in structure but the three most common ways are: Percentage-based pricing (also known as contingency), Volume-based pricing (flat rate per claim), and User-based (either per provider or per seat).  Ultimately, a billing partner should be, first and foremost, a partner and not a vendor.  Because of this, aligned incentive models (contingency and volume-based pricing) are usually best because they incentivize the partner to help enable growth and strong performance.  The better you do, the better they do so they are truly an invested partner.”

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At Healthie, we’ve seen the pricing model often depends on the value being provided by the organization. For billing partners that provide billing services, it’s not uncommon to be charged a % of the claim or allowed amount. These rates could vary anywhere from 2.5% to 8% depending on the level of services provided and how much human involvement there is.

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For clearinghouses or point solutions that complete a billing task like submitting a claim or running an eligibility check, you’ll typically find one of two models. The first model is per task, such as per claim submitted or per eligibility check run. These are often in the cents per task because at larger organizations their extremely high volume. Some companies, including some of those in our Harbor, offer an “all you can eat” model where they charge a provider license at $x per month for unlimited claim submission. 

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RCM solutions fall in the middle. They’re typically providing value-added technology and/or services on top of billing tasks such as claim submissions, and eligibility checks. For this reason, you may find an elevated subscription cost or a multi-product model that includes one fee for platform and another additional if you opt-in to more services for say things like coding.

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What to consider when evaluating billing solutions?

If you ask our partners, ClaimRev would say, Technology and Integration, Expertise and Support, and Transparency and Reporting. Superdial added on Compliance, billing partners have access to a lot of PHI and it’s critical they’re following all necessary security measures.

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It’s important to look at the size of your existing billing team to see what you want to take on versus what the partner needs to take on. Adonis shared, “For teams with a limited number of billers, it is important that the billing partner offers excellent integration capabilities and robust support to handle any issues that may arise. Small teams benefit from partners who can provide a broad spectrum of services, thereby minimizing the need for the internal team to manage multiple systems. This helps ensure that small teams can focus on core medical services without being overburdened by complex billing tasks.”

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Candid added that it’s important to not just evaluate your needs today but how they may evolve as you grow.

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“The size of the billing team can factor into the evaluation and decision but should be paired with the growth trajectory of the organization as well.  Billing platforms usually come in three flavors:  Software Only, Fully Outsourced or a hybrid of Software plus Services (usually a co-sourced model with shared responsibility).  An organization should consider a few factors when evaluating solutions against their in-house billing footprint. 

1. Is the organization planning to grow in volume and at what rate?  If so, is the goal to keep billing FTE cost flat?
2. Is the organization looking to reduce RCM FTE cost?
3. What is the efficiency and proficiency of the billing team?

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By considering these factors, you can better understand how important features like including billing services, automation, AI/ML and other efficiency levers are to your growth goals.”

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These items are key reasons why Healthie has a number of partnerships and primarily remains agnostic to our partners. If you ask us what billing partner can work best for you, it really depends on how you answer all the questions posed by our partners. 

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“Practices with moderate to large billing teams should look for billing partners that offer advanced tools to enhance efficiency and analytics to help in optimizing the billing processes. These practices should also consider partners with specialty-specific expertise that complement their existing capabilities and help in managing complex billing scenarios. Practices should ensure that their billing partner can provide customizable solutions that can evolve as the practice grows and scales.” This reminder from Adonis, points to thinking not just about the tasks of completing eligibility checks or submitting claims, but also looking at revenue intelligence and the overall performance of the billing department.

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The Financial Source of Truth

The final piece to consider is the varying levels of integration among partners. It’s important to think about where your financial source of truth lives, is that going to be your EHR or an RCM platform. The answer to this may depend on how well your EHR displays billing data to allow it to be your source of truth. In the instance the EHR focuses on billing partnerships, it can be important to evaluate how much data the billing partner is reading from the EHR so in being you financial source of truth, they are up to speed on information related to insurance billing and cash payments.

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‍View our billing partners here.

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Thank you to our partners! This article wouldn’t have been possible without the support of our amazing partners at Adonis, Candid, ClaimRev, and Superdial!