Do you have to change your EHR to outsource billing?

What stays in your system when you outsource billing?

Almost everything clinical and administrative stays put. The EHR or practice management system remains the system of record for charts, schedules, demographics, charge entry and the claim file. The billing team works in it, or from reports it produces, the way a new employee in your billing office would.

• Charts, orders and documentation, owned and controlled by your practice.
• Your clearinghouse connection, if you have one, and your payer enrollments.
• Your bank accounts and the payer payment instructions on file.
• Your fee schedule and charge master, which the billing team should change only with your sign-off.

The EHR hub lists 54 systems we work in. The outsourcing guide covers the wider decision.

What changes?

Four things change: access, the daily handoff, the way remittances are posted and the reports you receive. Access matters most, because the HIPAA Security Rule governs who may see electronic protected health information.

The Security Rule's access control standard says systems must allow access only to persons or software programs granted access rights, and it requires a unique user name or number for each user (45 CFR 164.312(a)(1) and (a)(2)(i)). Systems must also record and examine activity (164.312(b)), and the covered entity must have policies for authorizing access (164.308(a)(4)). In practice that means one named login per billing team member, never a shared one.

A billing company is a business associate. Before it handles protected health information, the covered entity needs satisfactory assurances documented in a written contract (45 CFR 164.502(e)), which is the BAA. The HIPAA rules for billing vendors page walks through the contract terms.

Who should be able to see what?

Apply the minimum necessary standard to the billing team: reasonable efforts to limit protected health information to what the task needs (45 CFR 164.502(b)). Give each role the screens it uses and nothing else.

Remove an account the day a person leaves the project. The audit log then shows exactly who touched which record, which is the point of the audit-controls standard.

How do claims and payments move between your system and the billing team?

Claims leave your system in the HIPAA standard formats. For professional claims that is the ASC X12 837 version 005010X222, and for institutional claims it is 005010X223 (45 CFR 162.1102). Payment and remittance advice return as the 835, version 005010X221 (45 CFR 162.1602). Your system or clearinghouse already speaks these formats, so the billing team does not need a new one.

Ask each major payer where remittances are sent before go-live, and keep the answers in one list the billing team and your administrator both hold.

Where should the payments land?

In an account your practice owns. For Medicare, the rule is specific: Medicare may pay an agent who furnishes billing and collection services only if the agent's compensation is not related in any way to the dollar amounts billed or collected, and payment to an agent is always made in the provider's name (42 CFR 424.73(b)(3)). Many billing fees are a percentage of collections, so the safe design is that payments go to a bank account in your name and the billing team never receives funds. Have your counsel confirm the arrangement for your payer mix.

What is the setup checklist?

When does a system change make sense?

Rarely because of outsourcing. A change is worth considering only when your system cannot produce charges, cannot create a standard claim file, or cannot give users separate logins. Even then, other options usually exist: a clearinghouse that builds the 837, a separate practice management module, or a scheduled charge report. If you are replacing the system for other reasons, finish the outsourcing handoff first or schedule the change in a quiet month, because two transitions at once make errors hard to trace.

Switching billing companies has its own checklist in how to switch medical billing companies.

How does Nucleus Align handle this?

We work inside the EHR or practice management system you already use, on named accounts your team issues after a BAA is signed, and we align each EHR, clearinghouse and payer portal workflow with standard claim validation, reconciliation controls and performance monitoring. Claims go out within 24 hours of charge entry. See medical billing and family medicine billing, read more on the blog, or book a call.