In House or Outsourced Medical Billing – Which Model Is Right For Your Practice?

The decision to change an existing medical billing model should not be taken lightly. Even the best case scenario involving a change to/from an in-house or outsourced medical billing model will involve some degree of short term cash flow disruption and we won’t even bring up the worse case scenario.

A health care provider’s first step is to determine whether or not his/her current medical billing model is achieving the desired financial result. Although financial analysis is beyond the scope of this discussion, the provider, accountant or other financial professional must be able to compare actual financial data to revenue and operating budgets. Assuming the integrity of the practice’s financial data is intact though accurate and timely data entry, the provider’s medical billing software should possess the capability of generating actionable management reports.

In the end, basic financial analysis will shed light on the strengths and weaknesses of the provider’s medical billing model. Some things to consider when evaluating a medical billing model: the inherent strengths and weaknesses of in house and outsourced medical billing models; the provider’s practice management experience & management style; the local labor pool; and medical billing related operating costs.

In House versus Outsourced Models

No medical billing model is without unique advantages and pitfalls. Consider the in house medical billing model. Approximately one third of independent health care practices utilizing an in house medical billing model experience cash flow issues ranging from periodic to persistent. The degree of action required by a provider to resolve his/her cash flow issues may range from a simple adjustment (adding staffing hours) to a complete overhaul (replacing staff or switching to an outsourced medical billing model).

The provider with an under performing in house medical billing model has a clear advantage over the provider with an under performing outsourced (also known as third party) medical billing model: proximity. An in house medical billing model is within walking distance. A provider has the opportunity to observe, assess and address – observe the process, assess the system’s strengths and weaknesses and address issues before they become full blown problems.

Consider the provider with an outsourced medical billing model. The relatively low entry barriers of the third party medical billing industry have led to a proliferation of medical billing services scattered throughout the United States. Chances are the provider’s medical billing service is located in another geographic area making first hand observations and assessments impossible.

The role of management reporting in a third party medical billing model is critical. A provider must regularly review charge entry, posting, write offs and account receivable balances to insure his/her cash flow is properly managed. A report as basic as 30, 60, 90 days in receivables will quickly give a provider a good idea of how well their medical billing and account receivable processes are being managed by a third party medical billing service.

A common mistake for many providers with an outsourced medical billing model is to gauge the effectiveness of the process in the very short term, i.e. week to week or month to month. Providers maintain a vague and informal sense of their cash flow position by keeping mental tabs on the checks they received this week versus the prior week or if they deposited as much money this month as last month. Unfortunately by the time a weakened cash flow gets the provider’s attention a much larger problem may be looming.

What causes a slow down in cash flow in the outsourced medical billing model? The most commonly cited scenario is lack of follow up on the part of the medical billing service. Why? Like any other business, medical billing companies are concerned first and foremost with their own cash flow.

A billing company generates 99.99% of their revenues on the front end of the billing process – the data entry process that generates claims. Billing companies that devote nearly all of their manpower to data entry will be understaffed on the back end of the billing process – the follow up on unpaid claims. Why? Every hour of data entry generates an additional one to two hours of claim follow up. Unfortunately for the provider, a billing company that ignores does not devote enough manpower to the diligent follow up of 30, 60, 90 days in receivables can mean the difference between a provider making a profit or suffering a loss during any given time.

Practice Management Experience & Management Style

Providers with practice management experience will be able to effectively manage or recognize and resolve a problem with his/her billing process before the cash flow crunch gets out of hand. On the other hand, providers with little to no practice management experience will more likely allow his/her cash flow to reach a critical stage before addressing or even recognizing a problem even exists.

Whether a provider with billing issues chooses to retain and fix their current model or implement an entirely different billing model will depend to a great extent on his/her management style – some providers cannot fathom having their billing staff out of sight or ear shot while other providers are completely comfortable with turning their billing process to a third party service.

Local Labor Pool

Whether a provider chooses an in house or outsourced billing model, a successful medical billing process is still contingent on the people involved in executing the medical billing process. On a side note, choosing office staff for an in house model is similar to choosing a third party billing company. Regardless of the model, a provider will want to interview the potential candidates or an account executive of the third party billing service for experience, motivation, team oriented personalities, highly developed communication skills, responsiveness, reliability, etc.

Providers with an in house model will have to rely on their human resource and management skills to attract, train and retain qualified candidates from the local labor pool. Providers with practices located in areas lacking qualified candidates or with no desire to get bogged down with human resource or management responsibilities will have no other choice but to choose an outsourced model.

Medical Billing Related Costs

As a business owner, the provider’s primary responsibility is to maximize revenues. A responsible business owner will scrutinize expenditures, analyze returns on investments and minimize costs. In an in house model, costs associated with the billing process range from the Internet access used to transmit claims to the office space occupied by the billing staff.

The most effective way to manage billing costs is for the provider to think of the sum of those costs as a percentage of the practice’s revenues. The provider’s accounting software should allow for him/her to classify and track billing related costs. Once the billing related costs are identified, dividing the sum of the costs by total revenues will convert the costs to a percentage of revenues.

The exercise of converting billing related expenses to a percentage of revenues accomplishes three things: 1) gets the provider, business manager or accountant in tune with the billing related costs of the practice; 2) provides a basis for more in depth analysis of the practice’s cost and revenue components; and 3) allows for easy comparison between the cost impact of the in house versus outsourced models.

The cost of an outsourced model is fairly straight forward. Since the fees of the vast majority of outsourcing services appear to be a percentage of a provider’s revenues, the annualized cost of the medical billing service’s fees will be a fairly close approximation of the provider’s billing related costs for this model.

In the event a provider is considering an outsourced model, he/she should keep in mind that this model is not necessarily the silver bullet to ending all billing related costs and headaches that these services tend to advertise. True the billing company will acquire some of the costs associated with the process but the provider will still need staff to act as the intermediary between the provider’s office and billing service, i.e. someone to transmit data to the billing service.

Costs will further increase for the provider if the billing service charges additional fees for add-on services such as on line access to practice data, practice management software, management reports, handling patient inquiries, etc. The actual cost of the service will increase even more if claims 30, 60, 90 in receivable are not properly worked to facilitate adjudication.


In summary, the provider must carefully weigh the pros and cons of each model prior to making a decision. If the provider is not comfortable or experienced analyzing financial data he/she must enlist the services of an accountant or other financial professional. A provider must understand the costs as well as the inherent pros and cons of each billing model.

Providers employing an in house model need to understand the true cost of their process. Determining the true cost not only requires accurate financial data and accounting but an objective evaluation of the components of his/her current process, i.e. technology and staff. Why? Outdated technology, under staffing, turnover, or unqualified staff may contribute to the appearance of a low cost of ownership but those shortcomings will ultimately cause a loss of revenues.

In the event a provider is determined to utilize a third party billing service, he/she should invest the time to thoroughly familiarize him/herself with the outsourcing industry prior to interviewing prospective billing services. The provider must understand the hidden costs associated with the outsourced model in order to make an informed decision.

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Medical Billing Services Save Heatlhcare Practices Money and Time

There are many reasons healthcare practices might outsource their billing to a professional medical billing service; confusing insurance requirements, staffing problems and just keeping up with industry changes are a few examples. In the end though, the reasons most medical billing companies hear about come down to the two driving principles of any business – Time and Money. This article discusses how medical billing services are able to create significant savings in time and money for healthcare providers.

Medical Billing Services Save Training and Research Time
- Some readers might take the short view and think medical billing companies just enter data into a computer and send it off to a clearinghouse. In reality medical billing is a detailed process requiring specialized skills and in-depth knowledge of medical practice management, insurance industry practices, and the regulatory framework around state and federal laws. Professional medical billing companies invest countless hours in training and research to keep abreast of current codes, submission requirements, industry trends and the needs of their clients.

Significant expenditures are also made to ensure medical billing companies are up to date on the latest software. In a constantly changing industry, software vendors are always finding new and better ways of supporting practice needs. It’s not practicable for small or medium sized practices to dedicate the time necessary to stay on top of the latest innovations.

These investments of time by professional medical billing services are often not considered by providers, but they eliminate endless hours otherwise spent in seminars, meetings with vendors, or on the phone with clearinghouses and carriers. This time savings creates a valuable commodity for a practice seeking the edge necessary to keep up with a rigorous patient schedule.

Medical Billing Services Save Operational Time
-Medical billing services are able to save operational time by leveraging the economy of scale and the efficiency of task specialization.

Professional medical billing companies, by their very nature, create an economy of scale in maintaining a team of medical billing professionals to provide services across several practices. This structure creates a well trained pool of resources to manage each practice’s needs rather than just one individual overseeing all billing functions. The team approach also removes interruptions to revenue flow that result from vacations, unexpected sick time and staff turnover.

Task specialization among teams further heightens the efficiency of medical billing companies. Through task specialization, a team of billers can accentuates individual skills and reduces distractions of other activities.

Consider a provider who sees an average of 30 patients per day, or a total of 150 encounters per week. The time required to generate and submit 150 patient claims and follow up with insurance carriers with a high lever of accuracy can take up most of the time of an in-house biller. But this is just the beginning. That same individual will also need to follow up on denied or partially paid claims, researching why and resubmitting for further review. Patient invoices require additional time- printing, stuffing and mailing- as well as posting payments, running reports and providing detailed analysis on the current state of the practice; all this just to meet the standard offering of professional medical billing companies.

Through task specialization, medical billing companies might offer each of its clients several billers submitting claims and reviewing insurance payments with the highest level of accuracy. At the same time, the service might have other individuals or groups dedicated to managing patient invoices and questions across several practices with increased efficiency. This approach maximizes the time available for each activity by specialists with a greater knowledge of their roles, and, again, guarantees minimal (if any) interruption during employee leave and staff changes.

Medical Billing Services Save Money
-Hiring and training new staff, employee benefits, vacation/sick leave, and staff turnover are just a few factors increasing the costs of managing an efficient in-house billing program. Added to the operational overhead of day to day billing, software/hardware maintenance, clearinghouse fees, postage, and so on, the list of expenditures for practices is endless.

Good medical billing companies will design their services around covering all of these costs and immediately do away with the problems they create. To clearly demonstrate how medical billing services can save practices money, let’s compare the core costs associated with in-house medical billing against working with a professional medical billing service.

Cost of In-House Billing:
Our comparison begins with a typical practice with one or two providers. Let’s assume this practice has a dedicated, in-house biller receiving an annual salary of $30,000, or about $14.50 per hour. The chart below outlines the additional costs of having a full time employee in the office to handle all aspects of medical billing.

Base Pay ————————–$30,000
Medicare and Social Security ———$2295
401K ——————————–$1080
Disability —————————–$720
Healthcare ————————–$5220
Time off —————————–$3270
Total labor for 1 in-house biller ——$42,585
Next, we’ll need to consider materials and fees. An average practice will probably upgrade computers and software every 3 years at a cost of about $6,000. Spread out over those three years, we’ll assume an average annual software/hardware expenditure of $2000. Since our practice will send out its own patient statements, we’ll need about $150 per month for postage, paper and envelopes, an annual cost of $1800. Clearinghouse fees for electronic claims will come to about $60 a month, or around $720 annually. For the sake of simplicity, we’ll forget for the moment that our biller will need a climate controlled workspace, lights, general office supplies and a desk.
Here’s what our list of software/hardware, materials and fees looks like:

Software/Hardware —————–$2000
Materials —————————$1800
Clearinghouse Fees ——————$720
Total ——————————$4520
Adding the two totals above (labor + materials & fees), the annual cost of medical billing services performed in-house by the practice comes to $47,105 per year. Of course this number might not mean much until we put it in perspective against teaming with a professional medical billing service. As we move forward, keep in mind this conservative estimate does not factor in those other costs mentioned above that are often hidden – ongoing training, unexpected leave and sudden staff changes.
Cost of Professional Medical Billing Services:
To evaluate the cost of working with medical billing services, we’ll assume our practice has contracted with a medical billing company for full service billing. This includes all of those activities that would otherwise have been performed by the in-house staff above; claim generation/submission, insurance follow up, patient invoicing and support, detailed reporting, expert practice analysis, etc. We’ll also assume the practice has negotiated a rate of 8% of collections with its professional medical billing service.

Note: Calculating costs for medical billing services will vary slightly depending on the fee structure but will usually be based on either a percentage of collections or a fixed fee per claim. For more information on fee structures, see Percentage vs. Flat Fee Pricing by Medical Billing Services.

Assuming our provider visits 30 patients per day, 50 weeks out of the year, we’ll have 7500 patient encounters per year. If each encounter results in an average reimbursement of $60, our receivables come to a little over $450,000 per year. At a rate of 8%, the annual cost for the professional service to manage all aspects of medical billing services for the practice would be $31,500. In comparison with in-house services that’s a savings of $15,600 per year!

In evaluating the benefits of outsourcing to a professional medical billing company practices should consider the overall savings in time and money, beyond just minimizing the hassles. Medical billing companies provide knowledge, training, continuity of operations and a network of support leveraging task specialization and the economy of scale. Medical billing companies are able to eliminate dependency on one or two costly staff members to maintain revenue flow for the entire practice.

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