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Health Administration icon Medical Billing Business Plan

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Physicians 1st Billing and Claims


Our position in the market will be a full-service medical reimbursement business with individual pricing. As stated previously, our goal is one-stop shopping for medical practices when it comes to administrative functions. Physicians 1st Billing and Claims Electronic Claims Service’s policy is to customize our charges based on the work we do, and the needs of each office. We find that each practice is unique and, therefore, we do not quote a “standard charge” for services.

Initially, Physicians 1st Billing and Claims will offer electronic billing of medical insurance claims. This is a badly needed service for most medical practices, and is even more critical since the Federal Government will mandate electronic submission of Medicare claims in the near future.

A detailed description of the electronic submission process follows. The data necessary to submit claims will be downloaded from the medical office and input into specialized computer software. The software performs certain generic edits on the data and stores the information. When a batch of claims is complete for an office, it is time to transmit to the national clearinghouse. The data travels via modems and telephone lines to the clearinghouse where the data is edited a second time. This second series of edits incorporates “insurance company specific edits.” Cooperating insurance carriers notify the clearinghouse of certain edits they feel are necessary to allow payment of their claims. These edits are performed on each claim before they are transmitted on to the carrier, thus guaranteeing accuracy and payment in most cases. Upon receiving the insurance claim from the clearinghouse, the carriers process the claim and send payment directly to the medical practice. With electronic transmission to the clearinghouse and on to the carrier, computerized data verification, and elimination of most of the human element, the process of claims payment is greatly simplified and accelerated. Physicians will no longer wait 30, 60 or 90 days for payment, but will have money in their hands usually within 14-18 days.

As practices begin experiencing the benefits of electronic submission, many will see the advantage of out-sourcing other administrative functions. Physicians 1st Billing and Claims’ full-featured practice management software will allow us to meet those needs. Patients can be billed for co-payments or amounts which their insurance company did not cover. Secondary and supplementary insurance can be tracked and payments and balances applied accurately. The software utilizes state-of-the-art, open-item accounting, where most other systems use balance-forward systems. Outstanding receivables can be tracked with insurance aging reports, in several different sequences for ease of use. A complete practice analysis will increase office efficiency by showing where money is coming from. For each procedure, the charges and percentage of total charges they represent are calculated and printed for immediate reference. Transaction Journals and Detail Ledgers provide an accurate overall picture of the practice.

With managed care sweeping the country, it is imperative for medical practices to evaluate the benefits they receive from affiliation with different organizations. Our managed care contract service tracks payments and analyzes the information to produce customized reports showing profitability, or lack of profitability, with each managed care facility. These reports are critical when decisions need to be made on renewing and negotiating contracts.

Claim Systems’ state-of-the-art software will allow the physician to do complete dictation transcription. This allows the physician to meet the needs of the new strict HCFA mandate on clarity of all Medicare claims.

3.1 Service Description

Physicians 1st Billing and Claims’ number one goal is to provide outstanding service.

We show our dedication to service by providing the physician one-stop shopping for all his or her billing and claims needs. The services we provide are as follows:

  • Complete patient record setup.
  • Electronic and manual medical claims filing.
  • Patient billing.
  • Claims posting and patient record updating.
  • Collection services.
  • Complete practice analysis.
  • Assistance in negotiating health care contracts.
  • Automated transcription service.
  • Volume discounting.

Initially we will focus on just claims filing. In the near future we will diligently pursue our goal of providing one-stop shopping for physicians’ medical office management.

3.2 Competitive Comparison

An evaluation is performed on each medical practice during the marketing phase. This will allow us to determine the needs of the practice and how to charge for services rendered.

During the evaluation certain facts are gathered, such as:

  • The time it will take to key patient and claims information into the software.
  • The approximate number of claims a practice will submit monthly.
  • The approximate “total dollars” a practice submits monthly to insurance carriers.
  • How accurate is the information obtained from the office (is it complete and easy to enter or does it require extensive editing and follow-up?).
  • How often will the information need to be gathered (based on claims volume).
  • What method is best to collect the information (personally, mail, FAX, Federal Express, downloading via modems).
  • What other services may interest the practice.

From this information Physicians 1st Billing and Claims will be able to customize charges for each practice. This ensures that the client is not being overcharged or undercharged for the services they desire. See the section on Pricing Strategies for additional information on customized pricing of services. Currently our competitors are not offering full analysis service. Our competitors also are not able to offer two-way computer communications and record posting and file updates.

3.3 Sales Literature

Included in the appendix to this plan are copies of Physicians 1st Billing and Claims’ sales brochure and tips brochure. These brochures were developed with the expertise of a national marketing company specializing in medical reimbursement issues. The sales brochure will be used in conjunction with sales calls. Physicians 1st Billing and Claims’ Tips brochure will be utilized as a direct mail piece. Also included are copies of business cards and stationery.

3.4 Technology

The computer software that is the crux of Physicians 1st Billing and Claims’ medical reimbursement business is state of the art. Physicians 1st Billing and Claims is running in Windows 95. The software was specifically developed as a tool for medical reimbursement consultants. This is important because some software being sold is written to manage a doctor’s office and does not necessarily incorporate all functions that are needed for consultants. The software also includes the latest features needed for managed care organization management, including tables for the numerous fee schedules which may be required, and customized reports to evaluate contacts.

The ET&T clearinghouse, which verifies the claims data, is highly respected in the industry. They are members of and have been certified by AFECHT, a national policing organization. They utilize the American National Standards formats recognized by Medicare and most commercial insurance carriers. They guarantee claims are 98 percent accurate before being sent on to carriers.

3.5 Future Services

As stated earlier in 3.1, Mary and John plan to initially process claims manually and electronically. As they gain experience, they will offer full medical office consulting services as follows:

  • Patient billing.
  • Collection services.
  • Assistance in negotiating health care contracts.
  • Automated transcription service.