Billing software questions and qualms do not stand a ghost of a chance against four industry experts

In 1996, Congress enacted the Health Insurance Portability and Accountability Act (HIPAA), which focuses on improving efficiency in health care by standardizing electronic data, including billing systems. HIPAA, also known as the Kennedy-Kassebaum Act, has far reaching implications, as it will affect everyone in the industry from health care providers to individual physician offices.

While the standardization of patient and billing records will prove convenient for the interchange of data between organizations, implementing this nationwide criterion means uprooting existing computer systems. Offices are expected to purchase new systems that comply with the new law—noncompliance comes with a severe penalty. How will chiropractors know which billing program best meets their needs?

Chiropractic Products asks four experts to discuss upcoming changes in billing software and necessary features to look for in a new program: Don Biresch, president of DB Consultants Inc, Ottsville, Pa, for 18 years, has been in the software industry since 1965 and has been developing billing software since 1983; Eugene Cianciulli, DC, MS, FICC, is CEO and chief clinical consultant of Pulse Software, Elizabeth, NJ; Jeff Hollander, president and CEO of HNA Computer Systems Inc, Brooksville, Fla, has 15 years experience in the software industry; and Art Waldman, senior software engineer for Life Systems Inc, Longwood, Fla, has been with the company and in the industry for 8 years.

Biresch (left): During the last decade, insurance billing requirements—particularly Medicare policy changes—have had the most impact on medical billing software. The new HIPAA billing changes are major and will cause all software vendors to make substantial changes to the insurance billing logic in their systems.

Cianciulli: Privacy, electronic claims submission, requirements from health care payors, and insurance carriers will determine the features of software programs.

Hollander: Government regulations and changes in law will impact systems from both a billing and security standpoint. Also, changes are being made toward global information-sharing so that patient records can be moved among disparate systems. Just as billing programs during the past 20 years have become more integrated with appointment scheduling, they will need to become more tightly integrated with electronic document storage and the ability to share documents—from admission forms to X-rays—with colleagues via fax or email.

Waldman: Computer technology has become more affordable. One feature that will make an impact is document imaging, which is the ability to digitally store paper files on a hard drive. This will definitely be a part of software packages.

Biresch: First, since HIPAA is changing the information required for both electronic and paper claims, it will affect all software programs. All of us in the software development business must make significant changes to our software so that users can submit insurance billing to meet the new rules established by HIPAA.

Also, we may finally see the death of paper claims once HIPAA and the American National Standards Institute (ANSI) billing rules go into effect. The Centers for Medicare and Medicaid Services (CMS) paper claim in use today does not provide for HIPAA data requirements. The cost of processing electronic submissions versus paper claims [significantly] reduces administrative costs.

Cianciulli: HIPAA compliance will mandate the protection of patient records and privacy. Coding errors as well as fraud surveillance will be greatly improved. Since portability of health care records will be enhanced, the liability for and protection of these records will be staggering.

Hollander: As a result of new HIPAA mandates, all prior standards have a finite lifetime before electronic billing must conform to the new formats.

Waldman: With respect to office management features, HIPAA can be summarized in four categories of health care electronic communication: 1) electronic claim submission (ECS) using the ANSI 837 claim format, 2) electronic remittance advice (ERA), 3) member eligibility checking, and 4) patient electronic medical records. Privacy is a consideration for all HIPAA issues that all software applications must meet.

Biresch: Obviously, the first thing to look for is HIPAA compliance. Any software firm that intends to convert its systems to meet the mandate must have already begun the process of changing its software. Making the move to HIPAA is not trivial from the software programmer’s point of view, so consider the software company’s readiness regarding the new requirements. Make certain that the software works with the latest Microsoft® Windows® or a Windows-compliant operating system—it is my opinion that competing operating systems are or will become obsolete, at least for billing programs. Since most offices use Microsoft Windows, this helps ensure that all software systems behave similarly for the greatest transaction efficiency. Also, when you evaluate a prospective billing system, look at its help system. Does it work like most other Windows systems? Does it follow the standard rules by Microsoft for help system compliance? Microsoft has published standards that all software developers are requested to follow in designing software to ensure that all systems behave similarly and have similar visual menus.

As for note-taking and appointment scheduling systems, most in the software business have realized that the talents required to create an outstanding billing system are not the same as those necessary to create a good scheduler. So, most simply provide a basic interface to the outside world, so that other vendors’ note systems and appointment schedulers can easily interface with our own billing systems or vice versa. The best schedulers and note-taking systems on the market today are very specialized stand-alone software programs, and they are not part of any one vendor’s billing system.

Cianciulli: Chiropractic physicians should look for programs that provide ease of entry and use; accurate accounting records and ledgers; and efficient billing. The ability to create and track invoices for an individual, a group, or multiple providers efficiently are also pluses. One other feature to look for is whether the software provides inherent protection against possible billing frauds and OIG requirements.

Hollander: It’s not just the features available, but also the depth of the features and how they are implemented. Workflow within the office needs to be considered. How many times a day does the typical office find the need to either modify or delete account or billing entries? Accounting programs, by necessity, will lock information after period closing. Billing programs, on the other hand, can be designed to allow modifications and deletions as long as audit trails are maintained that include the user who made the change. When in a patient’s account, how many steps does it require to move between billing, ledger, condition, patient information, or scheduler? A program may be called robust due to the number of features or the depth of the features.

Waldman: The features should be robust and designed so as not to interfere with simplicity of use. Integration is a key feature—data should have to be entered only once, thereby increasing staff productivity. Also, the flow of the program is important. It should speed up processing patient visits. Information, such as scheduled next visit, balances, and birthdays, should be available at a glance without having to navigate several screens.

CP: What customer service features should chiropractors expect from a billing software company?

Biresch: Annual service contracts are a way of life with software, and they are the user’s guarantee that the software designer is highly motivated to keep up with changes in insurance billing and other rules (HIPAA). Beware of vendors who do not advertise an annual maintenance fee or have one that is absurdly low. This fee is what keeps that vendor moving forward with your software from year to year, and it helps to guarantee that your software will still work 5 years from now.

Cianciulli: Excellent technical support is obviously a necessity. Equally important is the software company’s commitment to be current and compatible with today’s requirements and standards.

Hollander: Health care and software technology industries are dynamic. Therefore, the software company has to provide continued development of the functions necessary to comply with governmental and third party payors. In addition, there needs to be a support system in place inclusive of prompt help-desk support, email, fax bulletins, support documents available by fax-back, and interim updates that can be downloaded from the Internet. They should make use of technology to provide the fastest and most convenient method to assist clients in obtaining the information they need.

Waldman: Unlike other software products, the purchase of billing software should be the beginning of a long-term relationship. There are two major services chiropractic offices should expect and receive from their software company—technical support and training. Technical support, while available in many forms, such as phone, email, fax, and voicemail, is best provided via telephone. Chiropractors should be able to call their company and actually talk to a person. Training, whether via telephone, seminar, or onsite, should be offered at a reasonable rate.

Biresch: Whether the output is a [Centers for Medicare and Medicaid Services] (CMS) paper claim or an electronic file, the process of billing should remain essentially the same for users. The new electronic ANSI X12 format provides feedback to the submitter (which claims were paid, how much was paid, and exceptions) on a line-item basis. Unfortunately, these files are difficult, if not impossible, for an end user to read. Most software businesses are preparing to release new programs that will read and translate HIPAA compliant response files from carriers. In some cases, these programs will actually enter payment data into the billing software.

Cianciulli: Electronic filing should be as simple as creating a [CMS] invoice. It should be efficient, automated, and trouble-free. The invoice should also be tracked and logged, and resubmitting should be instantaneous. The software should also provide a method of viewing the invoice.

Hollander: This can be a complicated issue due to the variety of ways applications store data. Ideally, an application should be able to read a remittance file, print a report detailing actions taken on a service-by-service basis, allow the user to automatically apply payments to all affected services/bills, display the resulting status of those services (paid, partially paid, rejected, and applied to deductible), followed by individual changes such as generating bills to secondary carriers and automatic balance write-offs without accessing individual patient files.

Waldman: Electronic remittance and follow-up should be part of the software flow without special programs or extra steps.

Biresch: If the software is well-designed, there should be little difference to the data entry clerk as to whether the patient has regular insurance or is part of an HMO or PPO.

Various HMO and PPO rules can be applied by the billing software each time charges (visits) are added to the system once the software understands the specific standards.

Cianciulli: Whether billing to an HMO, PPO, or any managed care system, the billing should be exactly the same. The specific required data for the PPO or HMO should be automated and transparent to the billing process.

Hollander: The key is flexibility. HMOs handle billing in a variety of ways. Systems must be capable of handling each HMO type as a separate entity when necessary for both service entry and bill generation.

Waldman: Two words come to mind—graceful and transparent. Special information, such as fees and codes, should be easily defined once, and from that point on, it should be obvious to the user. In other words, the software should be designed so that anyone entering a transaction for a patient is confident that the correct fees and codes are being used. CP

Julie Z. Lee is a contributing writer for Chiropractic Products.