Most doctors I talk to today are worried about post payment audits but few of them ask the question, who is auditing my billing company? If they are looking for a billing company they should also be asking how that billing company measures quality and what the internal process is for this at that company. Below is an interview I conducted with Erez Lirov.

Most doctors I talk to today are worried about post payment audits but few of them ask the question, who is auditing my billing company? If they are looking for a billing company they should also be asking how that billing company measures quality and what the internal process is for this at that company. Below is an interview I conducted with Erez Lirov.

Erez's experience spans heading technology innovation for both startups and established companies in healthcare and financial services at Vericle, TradeMD, Sparta Systems, National Bank of Canada, PIMCO, and Harris Bank. Erez was awarded US patent 6,785,810 in data security. Erez also graduated with a BSc degree from Princeton University in1999.

Dr. Brian: Erez. When you started your billing company there were just a few doctors and hundreds of claims. Now there are hundreds of doctors and 80,000 plus claims/month. Some docs I talk to want a smaller company. Can you explain to doctors who are thinking about joining this "network" why they should see a big billing company as a positive thing?

Erez: A continuously growing billing network in terms of claim volume allows real-time audit of payer performance, timely discovery of underpayments and delays, reconstruction of payer's underpayment rules, and effective and informed follow up. However, the risks of errors and sabotage increase too in step with billing network volume because some data entry and most payment denial follow-up require manual processing.

Dr. Brian: So the bigger we grew the more error prone the things became and so more errors occurred?

Erez: Yes.

Dr. Brian: Why is that?

Erez: Early quality assurance (QA) processes, limited to occasional and random spot-check of data and follow up records, proved sufficient in discovering sub-standard data entry and follow up performance or saboteurs in small-size billing networks but failed to adequately mitigate error and sabotage risks in a larger size billing network. Accordingly, a billing network requires scalable audit processes to effectively catch and correct processing errors or sabotage attempts.

We need a way to be able to immediately pin-point problem areas so that they can be corrected. If an operator or an auditor is not improving their overall quality and continues to make mistakes, then they must be replaced.

Dr. Brian: How do you manage this problem across hundreds of operators and dozens of auditors?

Erez: The new and improved auditing process must make sure that it is:

1. Timely: We plan on a 24-hour turn-around-time
2. Comprehensive: Enough claims are being audited
3. Effective: Operators or auditors with a high error rate are flagged for retraining or replacement
4. Efficient: BPOs fund each level of increased scrutiny caused by their error

Dr. Brian: That is a huge task when we are talking about potentially hundreds of thousands of claims each month. How do you plan on accomplishing this?

Erez: Yes, and to accomplish this we have introduced our vision of a Multi-Level Quality Control (MLQC) program which is made up of four has four main improvements over the traditional, manual audit process:

1. Automated reporting (Pin-point "bad apples")
2. Multiple audit levels (BPO, QA Team, SPOC, SPOC Manager)
3. Audit workflow management (QA Workbench)
4. Automated sampling ("audit-risk" database)

See Part 2 coming soon!



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