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Playing the game, fighting the fight

October 23, 2012
by Dennis Grantham, Editor-In-Chief
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The leaders of behavioral health organizations are, by and large, steady, reasonable, and patient people. So, it is comparatively rare to find a “hot-button” issue that worries, bothers, or angers them as the issue of billing and claims processes with private insurers does.  

On “good” days, executives will describe the billing and claims process in terms of the revenue cycle, explaining that their teams have reduced A/R days, improved cash flows, and enabled clinical staffers to focus on their essential work. On “OK” days,” they might explain it as a game that must be played, a high-stakes debate in which the opponent is always chipping away at your core argument—and your reimbursement. And on bad days, they see it as a lopsided battle against a mercenary enemy.   

Finding people with the knowledge and staying power to play the game daily and “fight the fight” when needed isn’t easy, but it is essential to the success of any mental health or addiction treatment organization. And, say experts, it’s not enough to have someone with a talent for “medical” billing: you’ve got to find, and then keep, people who master the more specialized work of billing and claims in the field of behavioral healthcare.

For organizations struggling to do that, there is an alternative: a billing service. For a fee, either a fixed or volume-based percentage of paid claims, these services promise to play the game better than an in-house team and, when needed, “take the fight to the enemy.”

Us versus them

I found that these organizations, and particularly their leaders, have a certain feisty intensity that an executive or board member might welcome on really tough days. One such leader is Melissa Zachariasz, President of MedPro Billing (Tamarac, Fla.) who until 17 years ago, was an experienced medical biller for a large physician group. Her passion for the business comes from deep within.

She says she founded MedPro and got into behavioral health billing “after my father died from alcoholism when he couldn’t get the treatment he needed.  Back then, [the payer] wouldn’t precertify a patient for treatment unless they were jumping off a bridge, and sometimes not even then.” She continues, “When you would finally get it precertified, they would do anything, find any reason, to deny the claim.”

When her fledgling business “did well” working with one facility, another—faced with the prospect of closing its doors—sought help. Then others, and more after that. “I really never marketed the business until the last five years,” says Zachariasz, who is seen as something of a pioneer in the development of this specialty area of billing.  

Today, MedPro Billing and its employees are housed in a 10,000 square foot office, an office that features distinctly robust design. Says Zachariasz, “We were just joking that if Hurricane Isaac came our way, we’d all seek shelter at work—we’ve got a generator, back-up power, the works.”

Despite MedPro’s increasingly sophisticated surroundings, Zachariasz says that the business itself is quite simple: “What it is is fighting the fight, because insurance companies do not want to pay claims.” Later in our discussion, she put it more bluntly: “Their job is to keep the money.  My job is to get the money.”

The goal: “clean” claims

The package of capabilities offered by behavioral health billing companies, which include not only MedPro, but newer competitors including Medivance (Sunrise, Fla.) and Professional Revenue Recovery Solutions (PRRS, Sunrise, Fla.)  include billing and collections, behavioral health benefit verifications, and utilization review management.

 Medivance’s CEO, Neisha Zaffuto, also learned billing in the field of behavioral healthcare before becoming involved with the launch of Medivance in 2007. That company’s initial funding came from Zaffuto’s mother. And, while its original headquarters were in a two-bedroom apartment, the business has since grown into an 8,000 square foot facility housing some 60 employees.

“The key to a successful billing relationship is having the ability to process the claims ‘clean.’ You’ve got to have the relationships at the customer facility to ensure that you’re getting good data in, so you can get good claims out,” explains William McCormick, Medivance’s CEO. “The challenge of having to fight the insurance companies, of knowing the nuances of the industry, is what the billers and collectors enjoy most,” he explains, adding that after clean claims are submitted, “it’s all about becoming the facility’s ‘advocate’ for payment.”

He asserts that “treatment services really want to focus on the business of care. They don’t have the billing knowledge that it takes to really maximize their reimbursements. They don’t have people who are able to concentrate on that, eight hours a day. We free them to be the clinical advocates, and we are their financial advocates.”

Starting the conversation

What, we asked, are the problems and complaints that would-be customers face?  How does the conversation begin?

According to Scott Delmarr, CEO of PRRS,  service conversations usually begin when one organization hears that another is getting a higher level of reimbursement for a particular code or treatment. “Typically, an owner or an executive brings in the results of their billing group and says, ‘What’s the UCR (usual, customary, and reasonable fee) that you are getting for this procedure?’ When we show them and when they see a difference, they think, ‘maybe we should try this.’”

Delmarr asserts that in-house billing staffs often face common concerns and problems:  

1) They are limited by the knowledge and management style of the billing and collections manager.