5 risks associated with overseas ASC billing and coding

The advantages of ASCs outsourcing management of their revenue cycle are well known: you can achieve significant cost savings in staff, equipment and business office expense while a team of certified coders and ASC-experienced billing and collection staff work hard to decrease your days in accounts receivable and optimize your revenue.

This is all well and good, unless you contract with a foreign-based billing company or the American-based company you partner with outsources coding, billing and collections to another country.

Outsourcing medical billing out of the country can present several problems. As the access to electronic transmission and data processing has grown, outsourcing to other countries has become more popular, mainly because of the competitive rates. However, lower prices may bring significant risks. The reasons why overseas companies can offer lower rates is that their employees are less educated in the complexities of our federal and state healthcare regulations and thus more likely to make billing errors.

Here are five complications you may encounter when a foreign company manages some or all your revenue cycle.

1. HIPAA/HITECH compliance. The most important consideration when outsourcing to another country is safeguarding your patients' privacy and preventing the possibility of a HIPAA security breach. Although violations of HIPAA privacy and security can occur with in-house billing, it can present an even greater risk when medical billing is outsourced overseas. Increasing the amount of people who have access to your patients' confidential information also increases the risk for a security breach. Whether intentional or accidental, unauthorized disclosure of protected health information (PHI) is considered a violation of HIPAA. Outsourcing your billing does not mean outsourcing your liability; your organization is still responsible for any breaches of patient confidentiality.

HIPAA was enacted to protect the privacy rights of patients (PHI) and later amended (HITECH) to govern the use and disclosure of electronic health information (e-PHI). One of the main concerns when considering outsourcing to a foreign billing company is whether its staff understands HIPAA and HITECH regulations and takes the necessary precautions to protect your patients' privacy.

The U.S. government is currently conducting HIPAA audits and has legislated penalties of more than a million dollars per year for improper (purposeful or accidental) breaches of PHI. Whether you perform your billing onsite or outsource, your responsibility to protect PHI remains the same.

If you are considering outsourcing your billing to another country, it is imperative that you have:
• a signed business associate agreement with your off-site provider that contains the necessary HIPAA/HITECH clause that requires that the billing company follows the necessary security practices to protect PHI;
• requested the billing provider’s written HIPAA/HITECH compliance policies and procedures; and
• performed an assessment of the company and its HIPAA/HITECH security practices and verify that they meet the requirements to protect your patients’ PHI.

You should also be aware that even though the overseas billing company may sign a contract ensuring that they will pay any fines resulting from a HIPAA/HITECH breach, judgements against a foreign company are time-consuming and costly, as well as rarely being successful.

2. Transparency. Outsourcing to foreign billing companies typically eliminates real-time access to patient accounts and revenue cycle management reports. These companies often use their own software and only provide you with outdated/sporadic reports. With no oversight of data such as patient demographics, charges, third-party payer claims, payment posting and collection efforts, errors are more likely to occur, which may lead to decreased reimbursement and increased compliance concerns.

3. Customer service. One of the defining characteristics of ASCs is their pride in providing excellent patient care and communication. However, when outsourcing revenue cycle management to another country, patients may face several obstacles when inquiring about their financial responsibility, including the following:
• language barrier
• time difference
• privacy concerns about personal and medical information overseas
• complicated insurance coverage questions
• reaching the right person to address their problems

4. Performance. In most cases, the adage of “you get what you pay for” is inherently true when it comes to outsourcing billing tasks to an overseas-based company. There are many reasons why this company can offer you a lower price, most of which can be detrimental to your organization’s reputation. These include the following:
• lower pay often equals less experienced employees
• inadequate or no knowledge of U.S. federal and state regulations
• lack of revenue cycle policies and procedures
• higher turnover of employees due to low compensation and long hours

5. Real cost. Organizations are often enticed by the siren song of “low-cost” revenue cycle management offered by some overseas companies. However, you must consider possible additional costs.

A lack of on-location supervision and auditing with foreign billing companies often results in an increased frequency of errors. Errors must either be addressed before claims go out or when denials come, with both requiring constant oversight by your staff. Be sure to include the cost of this monitoring and necessary correction of errors when determining what you are actually paying for these services.
In addition, not all services are always included with foreign-based companies. Your ASC may be charged additional fees for services that should be included in an outsourced billing agreement.

No outsourcing of responsibility
It is your ASC's responsibility to safeguard patient privacy, ensure compliance with U.S. federal and state regulations, and ensure coding and billing accuracy and quality. When deliberating whether to outsource to a foreign country, don’t base your decision solely on price. Any anticipated financial gains may be offset by additional expenses for services, compliance risks, time-consuming oversight and decreases in patient and staff satisfaction. It's said that it is hard to put a price on peace of mind. On the other hand, it's hard to appreciate peace of mind until you no longer have it.

Caryl Serbin, RN, BSN, LHRM, is president and founder of Serbin Medical Billing, an ASC revenue cycle management company. Serbin Medical Billing's primary objectives are to provide the best coding, billing and accounts receivable management services available to ambulatory surgery centers (hospital joint-venture, corporate-owned or independent) and anesthesia providers. Ms. Serbin has been a leader in the ASC industry for 30 years. She was the founder of the first ASC-specific billing company.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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