PRACTICE POINTERS

Find a billing boss who fits the bill

Your cash flow depends on a staffer whose job consists of far more than getting the charges out the door.

By Robert Lowes
Senior Editor

Over the past five years, Alton (IL) MultiSpecialists has had five successive—but not necessarily successful—people run its billing and collections department.

In 1997, the practice decided that the job had outgrown its occupant, a woman—promoted through the ranks—whose brash and bossy ways didn't go over well with subordinates. Her college-educated replacement, hired from the outside, lasted two months because she was too shy to take charge.

The next billing boss had a longer tenure, but her gruffness alienated staffers and caused some to quit. High turnover contributed to rising accounts receivable.

Last year, the group hired an outsider who had the complete package of skills. "She was a people person as well as a financial type," says pediatrician Carolyn Brannon, who served on the search committee for the post. "When employees did something right, she praised them. Turnover slowed and the A/R fell, too."

The story didn't end happily ever after, however; the ideal billing chief left for a job with a shorter commute. But by then the group knew what to look for, and they brought aboard a replacement with the same blend of traits as her predecessor—numbers-oriented and personable.

While the 22-doctor Alton MultiSpecialists is ranked among the nation's 200 best-performing groups by the Medical Group Management Association, it resembles the average group in its struggle to find the right person to oversee billing and collections. Whether the position is called business office manager, patient accounts coordinator, or billing supervisor, it's a hard one to fill. "Few people can run a billing operation," says Lafayette, LA, practice management consultant Margaret Jackson. "They're like a needle in a haystack."

Staffers drafted into this role may know how to code charges, post payments, and generate A/R reports, but all too frequently lack managerial skills, such as how to motivate others and resolve conflicts. Those are especially important qualifications in hectic medical practices. "These people are talking to disgruntled patients, frustrated doctors, and insurers who won't listen," says Alton MultiSpecialists executive director Virginia Drone. "It's a thankless job."

In a time of declining reimbursements and increasingly restrictive Medicare regulations, doctors need first-rate billing managers more than ever. "They control the money," says Pam Wiese, executive administrator of the 14-doctor Orthopaedic Associates of DuPage in suburban Chicago. "And if the money doesn't come through the door, the practice disappears."

We talked to practice administrators, consultants, doctors, and others for tips on what to look for in a billing manager, and how to recruit or train one. If you follow their advice, you may land Ms. or Mr. Right on your first try.

Above all, the billing manager must manage

A billing manager won't live up to her title if she loses sight of the big picture—collecting revenue—and instead succumbs to what time-management experts call "the tyranny of the urgent." That means neglecting the most important tasks for those that are most immediate and pressing.

"I've seen billing supervisors who focus on the daily routines of submitting charges, posting payments, and depositing checks, but let delinquent accounts get out of control," says Janet McLaughlin with PMC-Consultants for Health Professionals in Burlingame, CA.

Effective billing managers think globally. Instead of burying themselves in coding, for example, they're studying A/R reports and explanation-of-benefit statements for patterns that may translate into tens of thousands of dollars in jeopardized revenue.

"A real manager follows the money," says Cheryl Toth, a Patagonia, AZ, consultant with Karen Zupko & Associates. "She doesn't get bogged down in petty tasks."

Your billing boss also must manage four key relationships with professional aplomb.

Subordinates: Can she listen to them? Communicate clearly with them? Train them? Evaluate their performance? Avoid playing favorites? And, most importantly, can she motivate staffers to work up to their potential? Some billing managers attempt to do this with dictatorial directives and cutting criticism. The best ones, though, rely on positive strokes: Pizza parties for a good month of collections, wall charts that show whether A/R is rising or falling, theater tickets for an insurance specialist who finally cleaned up a year-old account.

Doctors: The billing manager is responsible for informing the doctors in the practice about the status of collections, but she shouldn't overwhelm them with stacks of computer printouts, says Lansing, MI, consultant Gray Tuttle Jr. A smart manager will provide you with easily digested and meaningful information: What insurers are my slowest payers? What codes are producing the most denials? (See "Dump a health plan? How to decide.") Such a staffer sees the numbers through a doctor's eyes.

Insurers: Syracuse, NY, computer consultant Rosemarie Nelson knows of insurers who've threatened to disenroll doctors from provider panels because someone in billing and collections threw a snit fit on the phone about denied claims. Nelson recommends a more conciliatory approach.

"The billing manager should work within the insurer's rules instead of demanding that they be changed," says Nelson. If a billing manager has to confront an insurer about a problem, she should gather the facts and present them in a nonadversarial fashion. Insurers may seem like enemies, but you can't treat them as such—at least to their face.

Patients: When it comes to collecting from patients, a billing manager shouldn't use hardball tactics more suited for someone who's missed payments on a pickup truck. After all, patients are reluctant customers—they're sick and would rather not be in the doctor's office at all. So good billing managers make it clear that health is the true bottom line. They'll help patients in arrears set up face-saving payment plans. And when a bewildered Medicare recipient calls with questions, these staffers graciously provide answers.

Since billing and collections is increasingly automated, the person in charge must be computer literate, too. "She needs to harness all the features of the doctor's practice management system, especially when it comes to generating reports," says Nelson. "Too often, the software is underutilized."

How to find and evaluate outside job candidates

If you hire a billing manager from the outside, look for someone with several years of managerial experience. Candidates with a college degree—especially in a business-related field—deserve extra consideration. Some advertisements for billing managers even make higher education a requirement.

It's also good to know that prospects have passed the necessary tests to become "boarded" by professional organizations. The Professional Association of Health Care Office Management (www.pahcom.com ) knights worthy members as Certified Medical Managers. Certified Medical Reimbursement Specialist is awarded by the American Medical Billing Association (www.ambanet.net ). MGMA (www.mgma.com ) certifies members through its American College of Medical Practice Executives, although that's not a common credential for billing managers.

Fish for veteran coders, and certified ones at that. Organizations that certify coders include the American Academy of Professional Coders (www.aapc.com) and the American Health Information Management Association ( www.ahima.org ).

How do you amass a field of candidates? You can go the usual route of phoning a local medical staffing company or running newspaper ads. Further focus your ad campaign by posting the job at the Web sites of MGMA (click on the "What's Inside" box to get started) and PAHCOM (click on the "Career Center" listing).

And nothing beats networking. Contact the local or state chapters of MGMA and PAHCOM and ask if they know of any billing managers between jobs. Other doctors and practice administrators in town may be able to point out prospects.

Think twice about recruiting a billing manager from a hospital. Unless she's worked in a hospital-owned doctor's practice, she may be unfamiliar with physician coding. In addition, hospital culture is more bureaucratic in comparison with a physician's office, notes Cheryl Toth. "You want someone with a 'let's go' attitude."

Nobody will want to run your billing and collections department, though, if you don't offer enough money. The average salary for this position in 2000 was $39,012, according to the MGMA, but compensation varies by specialty, location, and practice size. (See "What billing managers get paid".)

Single-specialty groups with more than 25 doctors pay billing managers as much as $78,000. Single-specialty groups with four or fewer doctors should count on shelling out between $30,000 and $35,000.

Once you've attracted ostensibly strong candidates, determine whether their know-how lives up to their credentials. For starters, have them take the billing test found at the Web site of Karen Zupko & Associates (www.karenzupko.com/Resources/tools/Downloads/assessment.doc ). To go deeper, ask job candidates to produce customized spreadsheets, analyze recent A/R statements, and discuss how they'd handle various billing scenarios.

"Show them an EOB that reports a denied claim along with the statement 'Not eligible on date of service,' " says Toth. "You'd expect them to figure out what went wrong operationally in the office that produced the denial. Here, it's a case of the front desk not verifying insurance eligibility."

Also gauge how much burning passion they have for collections. "You want a billing manager who goes after the money like it's her own," says Margaret Jackson.

The right way to promote from within

Recruiting a billing manager from the inside has several advantages. "If the right person is promoted, it's good for office morale, because everybody can see that there's opportunity for advancement," says PAHCOM president Cathy Berto, assistant administrator for a multispecialty group in Melbourne, FL. And unlike an outsider, an insider already knows the practice's philosophy and office politics, so the transition is smoother.

Of course, beware of the Peter Principle: You may promote someone to their level of incompetence, as has often happened with coders and insurance specialists who were elevated to the top of the heap. However, such a promotion may be worth the risk if the employee has the potential to become a manager. In that case, provide on-the-job training.

Training resources are plentiful. Start with professional organizations such as MGMA, PAHCOM, AAPC, and The Medical Management Institute (www.the-institute.com). Aim to get your trainee certified where applicable. Community colleges offer inexpensive business classes. Your vendor for practice management software can sharpen a trainee's computer skills.

One way to develop a staffer into a billing manager is to try her out as a "lead" person or team leader. The lead person continues to perform her nuts-and-bolts job—say, following up on delinquent insurance claims—but also assumes limited supervisory duties, such as running department meetings, coordinating work schedules, assisting with job evaluations, and fielding questions from team members. This extra work merits a 10 to 20 percent raise, says Cheryl Toth.

If your practice has no more than three doctors, a lead person for billing and collections may be all you need, notes Toth. "Bringing in a $40,000-a-year manager is a big step, and it's not always necessary, especially if there are only three people in the billing department."

As the practice grows and suddenly seven or eight people are tending the dollars, a full-fledged manager makes more sense. The team leader you've groomed all along may be the best candidate for the job—a true collector's item.

What billing managers get paid

Source: Medical Group Management Association. Data for 2000. All figures are medians.

 

Robert Lowes. Practice Pointers: How to find a billing boss who fits the bill. Medical Economics 2002;6:73.