Third-Party Medical Billing

[influx65]

I was given a new requirement to create a BPA (or IDIQ, depending) for agency-wide use, for third-party medical billing. The program folks have provided the payment structure they'd like to see in place, which supposedly is consistent with how payment for this type of service is made to a third-party biller in the public sector. It involves a flat fee per encounter, plus a percentage of funds recovered, as an incentive. Since I've not previously worked on a project like this, I'd like to see how other folks in the federal government are paying their third-party medical billers, especially if they're incentivizing them in any way. Have any of you done this type of contract? And, can you point me to contracts already in place so I can see how fee and payment info was structured in other IDIQs or BPAs for this type of service? Thanks in advance for any help you're able to provide!

[FAR Fetched]

Did you get a proposal from the third-party medical biller? The program folks should have given you more than just how much their getting paid - what are they going to do (i.e. SOW). I'm sure the company has SLA's that are typical for their type of work; I don't know how you could generate them without knowing what they're commuting to doing.

[FAR Fetched]

You should also talk to you legal dept to see if the vendor is considered a "business associate" as defined in 45 C.F.R § 160.103 (also see the Electronic Protection Health Information EPHI also found there).

Again, not sure what their doing so I can't really help you.

And I strongly suggest that you not find a template and try to make a square peg fit into a round hole.

I'm sure you're familiar with HIPAA-AS

[j_dude77]

A family member owns a third party billing company, which I help out from time to time. There are probaly some that operate on the fee per action plus percentage of net. There are also third party billing companies that charge a percentage of what is billed (value of claim submitted). There are some that charge a percentage of net (what is actually paid). If you look at the rates you usually see the first type charge a lower percentage. This does not mean you are going to receive more money from claims. The second usually charge a higher percentage, but you will usually see larger returns due to recovering as much money from the claim, which makes the company more money. Is the company also going to do collections? That is something else that has to be considered. Many of these companies have agreements with collection agencies, or run their own. Sometimes this is part of the standard fee they charge. If you are interested, this is how the process works. The patient is seen at the facility, the facility forwards the information to the billing company of services rendered (coding). The billing company submits the claim to the clearing-house, and within a few minutes they will know if the claim was rejected or accepted. The claim is accepted and paid to the billing company. The billing company in turn takes their percentage and sends the remaining funds back to the facilty.

There are also other things you will have to take into consideration that may have not come into consideration. Some insurance companies may need information on new doctors at a facility, and will not pay a claim until this is received. Billing companies usually do not handle this. There are other scenarios, but that is one common example.

Good luck with this one.

[metteec]

I'd recommend that you ask the industry what is a standard commercial practice. Maybe you could issue a draft SOW or Request for Information on the Federal Business Opportunities website, and ask what sort of billing arrangements are standard in the industry. Then pick the strategy that would work best for you and your customer.

[C Culham]

influx65 - This post may be sharing something that you are already familiar with but meteec's response brought the documents to mind. Both of these documents may provide you further ideas on how you can research your question with industry.

http://www.whitehouse.gov/sites/default/files/omb/procurement/memo/myth-busting-2-addressing-misconceptions-and-further-improving-communication-during-the-acquisition-process.pdf

http://www.whitehouse.gov/sites/default/files/omb/procurement/memo/Myth-Busting.pdf

[influx65]

Thank you for the responses, thus far. To answer some of the questions, yes I do have a scope and no, I don't have a vendor quote, since this is still in the pre-solicitation stage. We've issued an RFI to determine standard industry practices, regarding billing for this type of service. So far, the vendor responses have been all over the place. Again, thank you for your responses.