Physicians have a lot on their plates. There is unyielding demand for better service, faster service, expanded service…the list goes on. That in itself is a challenge, but then there’s also the accompanying headaches of paperwork to do, calls to make, and emails to check. Oh, and don’t forget about billing. Getting fairly compensated for your efforts is unfortunately not a straightforward task. And in the grand scheme of the day’s activities, it tends to be one of the items on the list of to dos that is afforded the least care and attention. Coupled with the fact that it’s one of the least talked about and least understood facets of the profession it unfortunately results in physicians being underpaid, not coding properly and even being audited for unintentional mistakes. In Alberta for example, there are several documents which interrelate to each other and set the stage for how to approach billing. The Alberta Health Services Physician’s Resource guide, for example, is a resource that is available to physicians to provide a ‘digestible’ overview of how to approach billing. This overview document is 110 pages, containing eight headings:

  • AHCIP Basics for the Physician
  • Patient Basics - Eligibility
  • Claim Submissions
  • Special Situations
  • Out-of-Province Patient Claims
  • Reviewing and Reconciling Claim Results
  • Schedule of Medical Benefits
  • Legislation and Regulations

Each of these headings contains anywhere from seven to twenty sub-points and/or headings. Plus, there are four appendices which add still more “clarity” to the document. This document attempts to simplify how you can bill within the rules. But in order to really know the rules you have to understand the intricacies of the underlying documents it refers to, which are collectively referred to as the Schedule of Medical Benefits (SOMB). The SOMB comprises:

  • Explanatory Code List (57 pages)
  • Fee Modifier Definitions (21 pages)
  • Medical Price List (772 pages)
  • Medical Procedure List (332 pages)
  • Medical Governing Rules List (48 pages)
  • Six other documents

In aggregate, you would have to read almost 1500 pages to ensure you had a reasonable grasp of what can and can’t be done, situationally and for what specialty. As you can imagine, this is not feasible for most physicians, let alone needing to keep current with the constant adjustments to guidelines, codes and other facets of billing. That said, as a practicing physician, you are responsible for keeping up your knowledge and ensuring you are in compliance. If you are flagged as an outlier or trigger an investigation, referred to as a “compliance review”, it can really complicate your life. This rather arduous process, if inconsistencies in your claims are suspected, is a multi-step look back at your submissions. It will have you divert you and your staff’s time and energy away from your patients, and instead deal with their notifications which will include (their terminology again):

  • Initiation of the compliance review
  • Requests for documentation from you
  • Notification to you of compliant and non-compliant findings within the review
  • Requests for additional information from you
  • Conclusion of the compliance review findings
  • Providing you avenues of appeal

One resource physicians are heading to more and more is that of an experienced medical billing service such as ResolvMD. We are a full service billing company that knows the rules and regulations inside out. We stay on top of the complexities so you don’t have to. In effect, we are a data-driven, quality obsessed shield that protects you from having to experience an audit. Our proprietary Physician Insights Portal introduces an intuitive way for you to easily understand where you may be at risk and how to correct towards the acceptable benchmarks. We show you percentiles and absolute differences within your speciality for tailored knowledge that is relevant to you. You can see a deep-dive analysis of codes which allow you to see where you may be over-aggressive, or on the flipside, not optimizing enough. Staying within acceptable parameters is absolutely key to avoiding the aforementioned audit, or “compliance review”. Referring back, once again, to the Physician’s Resource Guide:

Providers must ensure that their records are complete, accurate and support the services provided and benefits claimed. This requires providers to understand and apply the Schedule of Medical Benefits and to ensure that their billing staff understand the Alberta Health rules and submit claims appropriately. Documentation in patient health records must be completed in a manner deemed acceptable by the Minister; The original documentation relating to the goods or services provided must be retained for not less than six years and make the documentation available to Alberta Health on request.

When you choose to work with ResolvMD, you choose to leave behind the stress that can come from having to contend with the complexities of billing and stay within the lines. Most physicians who are audited are not bad actors, they just were not properly armed with digestible information and knowledge that enabled them to make defensible decisions.

About ResolvMD:

ResolvMD is an experienced full service medical billing company that empowers physicians to bill more efficiently through data-derived insights and democratized knowledge. We believe you should be as confident and competent in your billing as you are in your practice. Our proprietary Physician Insights Portal harnesses the power of data to deliver customized insights directly to you in real time. No more second guessing or feeling like you don’t have the transparency and accountability that you deserve. Paired with the most modern and secure platform on the market, you can rest easy knowing that we are taking care of all your billing needs while fine tuning your ability to understand best practices and earn what you deserve.